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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 34-32.5-115(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. 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 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 thisform 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 /> Sign e d dated this 0* day of /d�iV /'� 2 u 2/ <br /> GJU�W S v�G If Corporation Attest(Seal) <br /> Applicant/O rator <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: D �' ��� �a/ Town/City/County Clerk <br /> State ofQf a� ) <br /> )ss. <br /> County of t\V)( v_ )The=nstrument was acknowledged before me this 5 day of 1 vtQX`%' �� tua1by W t?.1 me r as J of rQV N�1 TYI i <br /> Notary Public .inn <br /> M Commission expires: <br /> I� I <br /> Y p <br /> DAR <br /> NOTARY PUBLIC <br /> STATE OF COLORAD717 <br /> NOTARY ID 20054002 <br /> MY COMMISSION EXPIRES AUG <br />