2025-09-02_REVISION - M2011017 ‎(4)‎

• Permit No: M2011017
• IBM Index Class Name: Revision
• Doc Date: 9/2/2025
• Doc Name: Request For Conversion
• From: CRC Inc
• To: DRMS
• Type & Sequence: CN1
• Email Name: BFB
• Email Name: ZTT
• 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 34-32.5-112,C.R.S.,of the Colorado Land
Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form 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 permit pursuant to section 34-32.5-123, C.R.S.
4--
Signed and dated this 30 day of
e 1rc If Corporation Attest(Seal)
Applicant/Operator or Company Name
Signed: 41 Signed:
n Corporate Secretary or Equivalent
Title: Town/City/County Clerk
State of r)19'(,01/0(10 )
_ )ss.
County of )
Thee foregoing instrument was acknowledged before me this Q day of ,
J ,by` l i(A IL&.A ���-1.�_� C /,Y) as •-)kQ.S\ of CRC.- Y`(L.
OligedDEENAJOCOZZENS Cr •� ed to the Account of
NOTARY PUBLIC Withi med Payee Notary Public 919
STATE OF COLORADO Absence of Endorse t Guaranteed
NOTARY ID 20244003079 MOUNTAIN ANK My Commission expires: O( I c .— 8'
MY COMMISSION EXPIRES 01/23/2028
SIGNATURES MUST BE IN BLUE INK
You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a