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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)'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 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 o?' day of 4,,-' <br /> ( (32O2,j/ . <br /> • <br /> -T!'N rc9Z€A.9C t//rifij If Corporation Attest(Seal) <br /> Applicant/Operator <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: OcoA),2/ /.i'�✓� <br /> �� Town/City/County Clerk <br /> State of Cest•!*c�p ) <br /> )ss. <br /> County of Guy msesvt ) <br /> The foregoing instrument was acknowledged before me this act day of A <br /> ,by .3"-is\AY1 Cbt..11ACATYWN as of <br /> = Y MAMIE RISKS a s AQ444,L, <br /> r?el <br /> •NOTARY PUBLIC-STATE OF COLORADO ` Notary Public <br /> NOTARY ID 20224041376 <br /> MY COMMISSION EXPIRES OCT 26,2026 <br /> APRIPergromperwmpqpimpumpsi <br /> My Commission expires: Ct.-k a 6 1 a0a(p <br /> SIGNATURES MUST BE IN BLUE INK <br />