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_-7_ <br /> Certification: <br /> As an authorized representative of the appiicam,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 inowiedge,aii significant_vaivabie and permanent man-made structureks)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-i i5(4)(e)7 C.tt.S.). kNO Tr,: for i iv operations,the atiected area inciudes aii iands delineated by the permit <br /> boundary.) <br /> 3. No mining operation will be iocated on iands where such operations are prohibited by iaw(Section 34-32.5-1 i5(4)(f), <br /> C.R.S.). <br /> 4. As the appiicanvoperator,i ao not have any mining/expioration operations in the State of Colorado CUTTentiy in vioiation 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 penairy 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 /> leis form has been approved by the Mined Land[reclamation Board pursuant to section 34-32.5-1 i o,(.[c.J'.,of the(L olorado Lana <br /> Reclamation Ad forthe Extraction of Construction Materials.Any alteration or modification ofthis 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,CR.S <br /> Signed and dated this day of <br /> if Corporation Attest(Seal) <br /> Applicant/Operator <br /> C,tmP l i S;"M- <br /> Corporate Secretary or Equivalent <br /> Title: i( Town/City/County Clerk <br /> State of ) <br /> )SS. <br /> County of ) <br /> S i'_YJ� 24n��The foregoine instrument was acknowledged before me this � day of aSa3 <br /> by CfU'�G. i Q_'S+ty' as (),neCG&OY of C 1 ty1 384ynsb f1 S <br /> NICOLE THERESE SMITH <br /> NOTARY PUBLIC Nolaq Public N�LOle'T-v'4*,Sf <br /> STATE OF COLORADO <br /> My Commission expires: MC <br /> NOTARY ID 20234008593 t�'C.Lt (� �� I <br /> MY COMMISSION EXPIRES MARCH 6,2027 <br /> SIGNATURES MUST BE IN BLUE INK <br />