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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 Actfor the Extraction of Construction Materials. Any alteration or modification of this 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,C.R.S. <br /> Signed and dated this t LA �1,-. day of MC,,rC j,1 , 7 e2-� <br /> N.\0\c;-\ C I k r�C-j If Corporation Attest(Seal) <br /> Applicant/Operator <br /> Signed: L �� �� Signed: <br /> Corporate Secretary or Equivalent <br /> Title: C��;-'ti-4-'C Town/City/County Clerk <br /> State of ) <br /> )ss. <br /> County of ) <br /> ti <br /> The foregoing instrument was acknowledged before me this I- day of /l LCt,y C�I/1 r ZC))Lc <br /> by tl�(C i l( as C, (\ `r of A\\�'�E�\S1�' �\C6���"`�G_IA' <br /> () ,4Cn l,;_Laq <br /> CAROL�GRAY Notary Public <br /> i.:1. <br /> c!1'"r No�WyPale,>lMbdIr My Commission expires: � �' il i 1� 7 <br /> IC Commission WM* <br /> *Mbar 11 N 7936�T <br /> w <br /> Oolob�r 11, T <br /> SIGNATURES MUST BE IN BLUE INK <br />