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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)(axVHI). <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 ofthe 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 Mined Land Reclamation Boardpursuant to section 34-32 5-110,GIZS,of the Colorado Land <br /> Reclamation Act for theExtraction of Construction Materials. Any aheradon or modifrcadon of this form shall resuk in voiding any <br /> permit issued on the altered or modifed form and subject the operator to cease and desist orders and civil penalties for operating <br /> without a permitpursuant to section 34-325-123, C-IL& <br /> Signed and dated this 6 day of 1 v o ye mm r <br /> 1Z a 4 � <br /> If Corporation Attest(Seal) <br /> A t/Operator <br /> Signed: signed: <br /> Corporate Secretary or Equivalent <br /> Title: r I V �C ' /�L�1'/�r' Town/City/County Clerk <br /> State of <br /> County of <br /> The foregoi instrument w owledged before me is f`l day of <br /> by, as of <br /> Jr <br /> No rc <br /> My Commission expires: �=-F— <br /> SIGNATURES MUST BE IN BLUE INK <br />