2021-12-02_PERMIT FILE - M2021067 ‎(4)‎

• Permit No: M2021067
• IBM Index Class Name: Permit File
• Doc Date: 12/2/2021
• Doc Name: Application
• From: Asphalt Specialties CO Inc
• To: DRMS
• Email Name: ECS
• Email Name: MAC
• Email Name: AWA
• Media Type: D
• Archive: No

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Certification:
As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum
requirements of the following terms and conditions:
1. To the best of my knowledge,all significant,valuable and permanent man-made structure(s)in existence at the time
this application is filed,and located within 200 feet of the proposed affected area have been identified in this application
(Section 34-32.5-115(4)(e),C.R.S.).
2. No mining operation will be located on lands where such operations are prohibited by law
(Section 34-32.5-115(4)(f),C.R.S.;
3. As the applicant/operator,I do not have any extraction/exploration operations in the State of Colorado currently in
violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials
(Section 34-32.5-120,C.R.S.)as determined through a Board finding.
4. I understand that statements in the application are being made under penalty of perjury and that false statements
made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503,C.R.S.
This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5412,GRS,of the Colorado Land
Reclamation Act for the Extraction of Construction Materials Any alteration or modification of thisform shall result in voiding any
permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating
without a permitpursuant to section 34-32.5-123, CRS
Signed and dated this day of 2021
Asphalt Specialties Co.,Inc.
If Corporation Attest(Seal)
Applicant/Operator or Company Name
Signed: \\�_%�-��� Signed:
Daniel W.Hunt Corporate Secretary or Equivalent
Title: President Town/City/County Clerk
State of Colorado )
)ss.
County of Adams )
The foregoing instrument was acknowledged before me this-- �—day of Alb b y e M�e 12
2021,by Daniel W.Hunt as President of Asphalt Specialties Co.,Inc.
JA'`1 ICE!'90N r
NO a 1- -.�LIC
STATt ADO No Public
NOTAR 527
My Commission LAp. 1 29,2024 My Commission expires: a."d 0
JAN NELSON
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID 19994030527
My Commission Expires April 29.2024