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~ECEe@1E® <br />MAY 18 2005 <br />CertiTcation: <br />-6- <br />Cifeiefim of Minerals and GeolollY <br />As an authorized representative of the applicant, I hereby certify that the operation described has me[ the minimum <br />requirements of the following terms and conditions: <br />1. All necessary aggrovals 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 stnrctun;(s) in existence at the time <br />this 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 azea includes all lands delineated by the <br />permit boundary.) <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section <br />34-32.5-115(4)(1), C.R.S.). <br />4. As the applicant/operator, I do not have any mining/exploration operations in the State of Colorado currently in <br />---violation of the"p3ovisions of'the Colorado"Land Reclamation Act for'tfie Extraction of-Construction Ivlate'rials- <br />(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 <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />This jorm has been approved by the Mined Land Reclamation Board pursuant to section 34-31.5-I10,C.RS., ojthe <br />Colorado Land Reclamation Act jor the Extraction ojConstruMion Materials. Any operation or modification ojthisjorm <br />shall resuU in voiding any permit issued on the altered or modified jorm and subject the operator to cease and desist orders <br />and civil penalties jor operating without a permit pursuant to section 34-32-123, C.RS. <br />Signed and dated this 1 L `) day of _~~~~A , Z(,(}~,S <br />4 9ve! $C rQ~sr- ~' y,v if A ~h L? If Corporation Attest (Seal) <br />A ]!'s<ant/Cfperat6r <br />Signed: Signe <br />Corporate cretary o Eqm nt <br />Title: ,~~ ~ lt.c.ca~t~ _ _ _ _ _ __ _ Town/City/County Clerk <br />State of G't~ /D~'n ~n ) <br />ss. <br />County of ~~ rl! r FJ S ) <br />The foregoing instrument was acknowledged before me this -2~ h~ day of GLr" ""` ~ ~~O,s <br />_, by as .- /1//~ ,b ~ ify' of <br />Notary Public ~ ~ • <br />My Commission expires: = o`(-/oZ~C"~4 <br />:v '. r ~ 1~ : ~ 2 <br />SIGNATURES MUST BE IN BLUE INK /j :, : -\' <br />,'rryrr,.r..... •~''~~~' <br />