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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 />1. All necessary approvals from local government have been applied for (Section 34-32.5-11 l(l)(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)0, <br />C.R.S.); <br />5. As the applicant/operator, I do not have any mining/exploration 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 1 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 and desist orders <br />and civil penalties for operating without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this 2$ day of1� Z172D <br />-1", 41_isc� <br />Applicant/Operator <br />By: CraM �., $fterl <br />Title: �dv,a9c✓ <br />State offl�oc� <br />_ ) ss. <br />County of <br />If Corporation Attest (Seal) <br />0 <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this a day of a Oo�o <br />by C-_�C,CLA as r of } oA ��CoMpang <br />(Name) tle) (Applicant/Operator) <br />ERIKA COATE� <br />NOTARY PUBLIC Notary Public <br />''TATE OF COLORADO <br />`TARY ID 20194011508 My Commission expires: <br />MY' ' SSION EXPIRES MARCH 22, 2023 <br />SIGNATURES MUST BE IN BLUE INK <br />