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RECEIVE® <br />APR 1 8 2006 <br />-~- <br />CeRificatioa: <br />Oivisiun of iViinerals and Geology <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 govermnent have been applied for (Section 34-32.5-110(lxa)(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 />(Secion 34-32.5-115(4)(e), C.RS.). (NOTE: For 110 operatons, 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)(t), <br />C.R.S.), <br />4, As the applicanUoperator, I do not have any mining/exploration opemtions in the State of Colorado currently in violation of <br />the provisions ofthe Colorado Land Reclamation Act for the Extraction of Constmction 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 I misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />Thu josm has been approved by [heMined Land Reclamation Board pursuant to section 3¢32.5-IIO,C.RS, ojthe Colorado Land <br />ReclamationAdjortheFa7raclionojConstructionMaterials. Anya/terattonormodifuationojthisjormshaUretu(tinvoidingany <br />permit issued on the altered or modified jorm and subject the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant to section 34-32.5-123, C.RS. <br />Signed and dated this day of <br />If Corporation Attest (Seal) <br />Applicant/Operator <br />Signed: _ <br />Title: _ <br />State of_ <br />County of <br />ss. <br />The foregoing instrument was acknowledged before me this <br />_, by as <br />day of <br />Town/Ciry/County Clerk <br />Notary Public <br />My Commission expires: <br />Signed: <br />Corporate Secretary or Equivalent <br />SIGNATURES MUST BE IN BLUE INK <br />of <br />M'.~nin\sttiare\vsforms\Construction110 (Approved OS111/2005) <br />