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-7- <br /> Certification: <br /> As an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements of the <br /> following terms and conditions: <br /> I. All necessary approvals from local government have been applied for(Section 34-32.5-110(1)(a)(VIII). <br /> 2. To the best of my knowledge,all significant,valuable and permanent man-made structure(s)in existence at the time this <br /> application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br /> (Section 34-32.5-115(4)(e),C.R.S.). (NOTE: For 110 operations,the affected area includes all lands delineated by the permit <br /> boundary.) <br /> 3. No mining operation will be located on lands where such operations are prohibited by law(Section 34-32.5-115(4)(f), <br /> C.R.S.). <br /> 4. As the applicant/operator,I do not have any mining/exploration operations in the State of Colorado currently in violation of <br /> the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials(Section 34-32.5-120,C.R.S.). <br /> 5. I understand that statements in the application are being made under penalty of perjury and that false statements made herein <br /> are punishable as a Class I misdemeanor pursuant to Section 18-8-503,C.R.S. 1984. <br /> This form has been approved by the Mined Land Reclamation Boardpursuant to section 34-32.5-110,C.R.S.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modification ofthisform shall result in voiding any <br /> permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating <br /> without a permit pursuant to section 34-32.5-123, C.R.S. Q <br /> Signed and dated this `-yt day of <br /> 'k h I<K �i If Corporation Attest(Seal) <br /> p ' nt/Operator <br /> Signed: a Signed: <br /> Corporate Secretary or Equivalent <br /> Title: Washington County Employee Town/City/County Clerk <br /> State of �7 O('C�.(- ) <br /> ss. <br /> County of L }G <br /> e <br /> The foregoing instrument was acknowledged before <br /> me thisSt� � day of �_✓�-� <br /> by ��P P t L_k as�)GcI et of <br /> 4 <br /> NOTARY PUBLIC Notary P is <br /> STATE OF COLORADO <br /> NOTARY ID 19964012722 My Commission expires: <br /> my Commission Ex Tres August 10,2020 <br /> SIGNATURES MUST BE IN BLUE INK <br />