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~- <br />Certification: <br />As an authorized representative ofthe 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 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 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 />(Section 34-32.5-115(4)(e), C.R.S.). (NOTE: For 110 operations, the affected area includes all lands delineated by [he 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)(£), <br />C. R.S.). <br />4. As the applicant/operator, I do not have any mining/exploration operations in the State ofColorado currently in violation of <br />the provisions ofthe Colorado Land Reclamation Act forthe Extraction ofConsVUCtion 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 [hat 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 the Mined Land Reclamation Board pursuant to section 34-32.5-IIO,C.R.S., ofthe Colorado Land <br />Reclamation Act forthe Extraction ofConstructlon Materials. Any alteration ormodification ofthlsform shall result in voiding any <br />permit issued on the altered or modified form 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.R.S. <br />+ aoo4, <br />Signed and dated this ~ ~ ~-' day of ~ pC t ~ , <br />Grand County Department of Road and Bridge <br />ApplicanUOperator <br />Signed: ~i~L X~ <br />Tide: Assistant Superintendant <br />Stale of Colorado ~ <br />ss. <br />County of Grand ) <br />r <br />If Corporation Attest (Seal) <br />, <br />Sig ~ <br />Corporate•Secretary or Equivalent' - <br />• ,-+-.. <br />=i owrJCity/County Clerk ' <br />-. ~: ~- <br />The foregoing instrument was acknowledged before me this o~l ~ day of Or~i ~ ~ o?Ul~(D <br />by sill Clark i~w~.. as Assistant Superintendant of <br />i~ <br />Grand County Department of <br />r®o<a <br />Notary Public <br />My Commission expires: ~.~7 3~ O ~ <br />OF <br />MUST BE IN BLUE INK <br />M:\min\thare\vsforms\Constmction I l0 (Approved OS/11/2005) <br />