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-�- <br /> Certification: <br /> As an authorized representative of the applicant,l hereby certify that the operation described has met the minimum requirements of the <br /> foliowing 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)(�, <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 forthe Extraction ofConstruction 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-IIO,C.R.S.,of the Co[orado Land <br /> Reclamation Act jor the Extraction of Construction Materia[s. Any alteration or modification of this form sha[[�esult in voiding any <br /> permit issued on the altered or modifted form and subject the operator to cease anct 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 /� day of /�,�v'/L , Z�22 <br /> �t�=�= `�.�w..��-%� If Corporation Attest(Seal) <br /> ApplicandOperator <br /> Signed: ���� �17i1.��� Signed: <br /> Corporate Secretary or Equivalent <br /> Title: Vice President Town/City/County Clerk <br /> State of �a I����v ) <br /> )ss. <br /> County of �/,�,�-� o S� � <br /> The foregoing instrument was acknowledged before me this /-� � day of ,��,—, � �U -� � , <br /> �� <br /> , by 1� 2 �� ���\Ct����-� as �r' C._E? �����CtC=h�" of !41 S (i�f� I,-�, �� -- <br /> SHtELA SUSAN MARfCU3 �'�`�/"` �� �r ������ <br /> NOTARYPUBLtC Notary Public <br /> 5TATE OF COLORADO ,/ <br /> NOTARY ID 20164034497 ��ly Commission expires. __�_��� ��� " ��� �� 7` <br /> MY COMMISSION EXPIRES SEPTEh�3ER 8 2024 <br /> ,I�.���'a�1�M� ��➢_ fiT' �3F �0 [�➢ � �� I�� <br />