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~- <br />Certiticatton: <br />As an authorized representative of the applicant, ]hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and petmanentman-made structure(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-L]5(4)(e), C.R.SJ. <br />2. No mining operation will be located on lands where such operations aze prohibited by law <br />(Sechon 34-32.5-115(4)(fl, C R.S.; <br />3, As the apphcant/opera[or, I do not have any extraction exploration operations in the State ofColorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Constmction Materials <br />(Section 34-32.5-I20, C.R.S.) as determined through a Boazd finding. <br />4. 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 l misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This jorm has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-171,GR.S., ojthe Colorado Land <br />Reclamation Act jor the Extraction ojConstruction Materials. Any alteradon or modrfrcation ojthis jorm steal(resuU in voiding any <br />permit issued on the aftered or modifred jorm and subject Jhe operator to cease and desist orders and civil penakies jor operating <br />without a permit pursuant to section 34-32-713, C.R.S ~ ~ ~ f <br />Signed and dated this 2y day of do ~ d <br />Clear Creek Distr+ Water Providers, LLC <br />Applican~Operator or pa y N <br />Signed• <br />I ea <br />Signed: <br />Title. ~~~~~/ <br />State of~'~l e/!JV/GJ ) <br />County of ,~ ~Q h0,___ L _. s <br />C <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this ~ day of ~lJUGI' <br />_, by ~nfxrfi ~• L.d/12f~{. as /~~L/ ofPlgal-~rr~lclJ~st~,ditll,~ir~P~rn~~ <br />p ~~ <br />~f~i,,2L,au,~o ~l~c-~t~ <br />~-.-.- - <br />Notary Public <br />My Commission expires• ~ ~ J` <br />SIGNATURES MUST BE IN BLUE [NK <br />