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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 34-32.5-1 15(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 fo•eue has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-110,C.R.S.,of the Colorado Land <br /> Reclauuuation Act for tlee Extraction of Const►•euctioi Materials. Arty alteration or modification of this forin shall result in voiding any <br /> pereeut issued on the altered or modifted forme and subject the operator to cease and desist orders and civil penalties for operatine <br /> without a per►nitpursuant to section 34-32.5-123, C.R.S. <br /> Signed and dated this day of y<�! c__. - c_.'. • <br /> If Corporation Attest(Seal) <br /> Applicant/Operator <br /> Signed: / Signed`l"GVG"y <br /> /� <br /> Corporate Secretary or Equivalent <br /> Title: u� '.�$ 1)111�64— Town/City/County Clerk <br /> State of CCU,or-&A o <br /> )ss. <br /> County of Mks S C ) <br /> The foregoing instrument was acknowledged before me this �'Z day of ws 3' 2 a? m , <br /> by Ire. V- 1�e �.1� as p4Lbljr. 1)c rV,.c D Yrula r of �. ��te�d A,. -LAso.r <br /> HANNA M. COSTANZO otary Publ' <br /> NOTARY PUBLIC <br /> STATE OF COLORADO My Commission expires: <br /> NOTARY ID 020124044930 <br /> My COMMIUlon Expires July 23,2024 <br /> SIGNATURES MUST BE IN BLUE INK <br />