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-5 - <br /> Certification: <br /> As an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements <br /> of the following terms and conditions: <br /> I. All necessary approvals from local government have been applied for(Section 34-32.5-11 l(1)(a)(IX)); <br /> 2. This entire mining operation will not affect more than 30 acres; <br /> 3. This mining operation will not adversely affect the stability of any significant, valuable and permanent man-made <br /> structure(s) located within two hundred (200) feet of the affected lands. (However, where there is an agreement <br /> between the applicant/operator and the persons having an interest in the structure that damage to the structure is to be <br /> compensated for by the applicant/operator(Section 34-32.5-115(4)(e), C.R.S.), then mining may occur within 200 <br /> feet. Proof of an agreement must be submitted to the Office prior to the decision date.) <br /> 4. 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 /> 5. As the applicant/operator, I do not have any mining/expIoration operations in this state of Colorado currently in <br /> violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br /> (Section 34-32.5-120,C.R.S.)as determined through a Board finding. <br /> 6. I understand that statements in the application are being made under penalty of perjury and that false statements made <br /> herein are punishable as a Class I misdemeanor pursuant to Section 18-8-503,C.R.S.. <br /> This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-111, C.R.S., of the <br /> Colorado Land Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form <br /> shall result in voiding any permit issued on the altered or modified form and subject the operator to cease aiddefst orders <br /> and civil penalties for operating without a permit pursuant to section 34-32.5-123,C.R.S. �` 'O •� <br /> g /�P� r �J <br /> Si ned and this���y of Q (� <br /> If Corporation Attest. eal) �} <br /> Applicant/Operator �'• <~ <br /> By:Soar. 9-4&w _s By: D <br /> Corporate Secretary or Equivalent <br /> Title:S WI..L, OJO.r k Town/City/County Clerk <br /> State of Cc I b rale ) <br /> 1,' )ss. <br /> County of ttit�8d <br /> The foregoing instrument was acknowledged before me this � day of <br /> 1,-{ <br /> by Tv�;l\ten G(6 W,&, as �4d.t Q r�1 L S•c.,�.,.(�,sar of trim sd,a . f^a L-- / <br /> (Name) (Title) (Applicant/Operator) <br /> I <br /> NO ARY P1321'9c: <br /> BT:N F CDC.C0' 0rZAD0 tary Public <br /> NOTARY ID 19914002032 <br /> SAY COMMISSION EYNl1?ES MARCH 9,2023 <br /> My Commission expires: 0 3--a9 -ZDa.3 <br /> SIGNATURES MUST BE IN BLUE INK <br />