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-~- <br />Cert'rficatioe: <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 />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 inthis application (Section 34-32.5- <br />115(4)(e), C.R. S J. (NOTE: For 110 operations, the affected area includes all lands delineated by the permit boundary.) <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-I 15(4xfj, C.RS.). <br />4. As the applicanUoperator, I donot have a~mining/exploration operations in the State of Colorado currently in viohrtionofthe <br />provisions of the Colorado Land Reclamaton 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 madeherein are <br />punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. 1984. <br />77ris form has been approved by the Minedland Reclamation Board pursuant to section 3¢32.5-110,CRS, ojthe Cobrado Land <br />ReclamationAdjorthe Extraction ojConstruction Materials. Any aUeration or modification ojthisjorm shall result in voidotg any <br />permit issued on the abered or mod~d jorm and subject the operator to cease and desist orders and civil penah9es jor operating <br />without a pennitpursuant to section 34-32.3-123, CRS. <br />nd ~ rU~ <br />Signed and dated this ~ day of ~ y a~ 00~ . <br />Title: ~-Q~- <br />Signed: <br />ApplicanUOperator <br />State of Q/c~,G~ ) <br />ss. <br />County of 1 <br />ff Corporation attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/Ciry/County Clerk <br />The for oing instrun t w s a cuowledged before me this ~ day of <br />by !O~ as ~~/1~/I of <br />,ounun.,,,,~,_ <br />A <br />00 fo <br />.~il._. C <br />~/7 Zi~~~ <br />My Commission expires: <br />F 0 F ~ p~, ~,.~` SIGNATURES MIIST BE IN SLUE INK <br />,~„~o~d <br />M:\min~vhare\v~o+ms\Convtruction110 (Approved OS/112005) <br />All necessary approvals from local government have been applied for (Section 34-32.5-110(1)(a)(VITT) <br />. ~,~ .s'. <br />