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- 6- <br /> Certifcation: <br /> As an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements of <br /> the following terms and conditions: <br /> 1. All necessary approvals from local government have been applied for(Section 34-32.5-111(1)(a)(IX)); <br /> 2. This entire nursing 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 between <br /> the applicant/operator and the persons having an interest in the stricture that damage to the structure is to be compensated <br /> for by the applicant/operator(Section 34-32.5-115(4)(e),C.R.S. 1984,as amended),then mining may occur within 200 feet. <br /> 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 <br /> (Section 34-32.5-115(4)(f),C.R.S. 1984, as amended); <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 Constriction Materials <br /> (Section 34-32.5-120, C.R.S. 1984,as amended)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 <br /> made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503,C.R.S. 1984, as amended. <br /> This form has been approved by the Alined Land Reclamation Board pursuant to section 34-32.5-111,C.R.S., of the Colorado <br /> Laird Reelartratiotr Act far the Extraction of Construction Alaterials. Airy alteration or modification of this form shall result in <br /> voiding any permit issued on the altered or nrodifted form and subject the operator to cease and desist orders and civil penalties <br /> for operating without a permit pursuant to section 34-32.5-123, CR.S. <br /> Signed and dated this day of f'�7v2z<A-/z-Y <br /> Ames Construction, Inc <br /> If Corporation Attest(Seal) <br /> Applicant/Operator <br /> By: By: <br /> � ff � EA- Corporate Secretary or Equivalent <br /> Title: V LGC 6�'/c�S1P `T— Town/City/County Clerk <br /> State of�32A%Z�C�' ) <br /> )ss. <br /> County of <br /> The foregoing instrument was acknowledged before me this k day of k <br /> by \CZ�C�� c��C� as��Ce�' cZESi�t �,'r of�M�SConS�ZvcTlotio 'Zk► Q . <br /> �C YI YC\ \ z5ct <br /> Notary Public <br /> CATHERINE ANN HARRISON <br /> My Commission expire. : NOTA, Y PUBLIC <br /> STATE OF C LORADO <br /> NOTARY 10 19974014716 <br /> SIGNATURES MUST BE IN BLUE INK My Commission Expires August21,2021 <br />