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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 /> 1. 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 1 misdemeanor pursuant to Section 18-8-503,C.R.S. 1984. <br /> This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-110,C.R.S.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Material& Any alteration or modification of this form 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 , ' •rmit pursuant to section 34-32.5-123, C.R.S. <br /> 9 t�� . d is .fit`�` day of n,�A.1�. l 10 . <br /> 1 <br /> Air �I_. -� ff,V If Corporation Attest(Seal) <br /> i ant/Operator <br /> � <br /> i <br /> Signed: • Signed: <br /> Corporate Secretary or Equivalent <br /> Title: t''' ' Town/City/County Clerk <br /> State of OV.A.a/k/01114-1 ) <br /> s. <br /> County of <br /> CUtkkA >) <br /> The foregoing instrument was acknowledged before me this 9-1 day of Y\avriii\-- , <br /> ,by as of . <br /> \i4h) ailikk\ ++ <br /> Notary Public <br /> My Commission expires: 1 1 �J/-y <br /> SIGNATURES MUST BE IN BLUE INK SA ANp,Q� <br /> .mssP+otagy ti, <br /> co isoo1s2s <br /> e,u/27,22< <br /> T 41)60G <br /> �OFOA(* <br />