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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(l)(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 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 Materials. 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 a permit pursuant to section 34-32.5-123, C.R.S. <br /> Signed and dated this %-15- day of DeCz-vK6 CV_ r}G4 C <br /> Sn Q-'fie-- Gun,�Arl-1 A L n , 1'n C. If Corporation Attest(Seal) <br /> Applicant/Operator <br /> Signed: L' Signed:(` Y!�'(4Q <br /> / Corporate Secretary or Equivalent <br /> Title: 00i r _ / CG i' Town/City/County Clerk <br /> State of 0,o%raclo <br /> ss. <br /> County of /Z/�19 r' ) <br /> The foregoing instrument was acknowledged before me this �` day of ��LL1QiT/6-0 r-, <br /> ,by Q��c�Li Urlatz' as Dt0-VrlCiDC/Q1['Y of�17QrQ. �oi)S�ruC{iQ/J ZY1G. <br /> JEANNINE V KUNTZ <br /> NOTARY PUBLIC Nota ublic <br /> STATE OF COLORAD <br /> NOTARY ID 19964000541 My Commission expires: 142NZ214 <br /> MY COMMISSION EXPIRES JANUARY 29,2024 <br /> SIGNATURES MUST BE IN BLUE INK <br />