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r <br /> rtif.__. cation: <br /> an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements of the <br /> tbllowing 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. 1 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)Alined Land Reclamation Boars/pursuant to section 34-32.5-110,CR.S.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction 1Llaterials. Any alteration or modification of this form shall result in voiding any <br /> permit issued on the altered or modifred 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. <br /> Signed and dated this (" day of <br /> J <br /> 7 t If Corporation Attest(Seal) <br /> Applicant/Operator <br /> Signed: ) /if.1/li�-o ,cZE�a , Signed: <br /> Corporate Secretary or Equivalent <br /> Title: Town/City/County Clerk <br /> State of y ) <br /> Ss. <br /> County ofAl <br /> St <br /> The foregoing instrument was acknowledged before me this day of <br /> by Janice Evans as of <br /> 1PaY °�a LINDA KAY WILKERSON Notary Public �� <br /> ?° NOTARY PUBLIC-STATE OF TEXAS <br /> r, T� ID is 798738.8 <br /> 'rEOFt�+� COMM. EXP.09.21.2023 ��ly Commission expires: <br /> SIGNATURES MUST BE IN BLUE INK <br />