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RECEI~E® <br />APR 1 8 2006 <br />-~- <br />llivision of Minerals and Geology <br />Certification: <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has metthe minimum requirements ofthe <br />following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 34-32.5-I10(1)(a)(VIII). <br />2. To the best of my knowledge, al] significant, valuable and permanent man-made stmcture(s) in existence at the time this <br />application is Sled, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-115(4Me), C.RS.). (NOTE: For 110 operations, the affected azea 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 applicanVoperator, l do not have any miningizxplomtion 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 theMined Land Reclamation Board pursuant to section 34-32.5-IIO,C.RS, ojthe Colorado Land <br />Reclamation Act for theFaYraction ojConstruction Materials. Any alteration or modifua6on ojthrs jorm shall result in voiding any <br />permit issued on the altered or modified form and subjeM the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant to section 34-32.5-I23, C.RS <br />Signed and dated this ~ ~ day of d '^^ ~ ~ ~ ~ 6 <br />~ea ~ /1~~~-~S <br />~ l <br />ApplicanVOpentor <br />If Corporation Attest (Seal) <br />Signed~~ ~/~" t--~~/ /' <br />Tile: ~en «-.--- ~ c'b ~ e-e-T C~ P r7/ 5 7t - <br />State of L ~~(~.y~~%~ _~ <br />1~ ss. <br />County of L/ ~ ,.~ ) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this `~ ~ day of ~~ ano[.. , <br />-, by sS e.; i'r T ~~~ 5 as ~~„ ~L of <br />GAIL ~ j-NotafyPublic <br />wens <br />-, ~ My Commission expires: ~-h - ~Ot7 ~ <br />INK <br />M:\min\share\vsforms\Cons[ructionl (0 (Approved OS/t ]/2005) <br />