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., <br />-6- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements <br />of the foIlowirrg terms and conditions: <br />All necessary approvals from local gcvemment have been applied for (Section 34-32.5-110(1)(al(viii). <br />2. To the best of m3' larowledae; all significant, valuable and permanent man-made structure(s) in existence at the time <br />this application is Sled, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section34-32.5-115(4)(e), C.RS.}. (NOTE: For 110 operations, the affected area includes all lands delineated 6y the <br />permit bounda.~~.) <br />3. No minurg operation will be located on lands where such operations are prohibited by law (Section 34-32.5-1 I S (4)(f), <br />C.RS.). <br />4. As the applicant/operator, I do not have any mining/prospecting operations in the State of Colorado currently in <br />~zolation of the provisions of the Colorndo Land Reclamarion Act for the Extraction of Construction Materials (Section 34- <br />32.5-120, C.RS.). <br />5. I understand that statements in the application are being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. 1984. <br />Signed and dated this,, day of /~ 1 CSl)t.C`.1v , ,~aD3 <br />Phillips County If Corporation Attest (Seal) . <br />ApplicandOperator :. <br />Signed: e ~,ru111w.r 0~-r~C <br />Title: ~ yy~rtt.deLl//Cct,J <br />Signed: ~T~'1 l :c-www.~ vin. <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of Colorado ) <br />55. <br />County of~hillips ) <br />The foregoing instrument was aclmowledged before me this ~/ ~~" day of ~ .Zv[z3, by <br />Susan Roll ~ as Commissioner of Phill;nc County <br />Notarv Publi <br />My Commission expires: ~ 9 -.Z, o D <br />SIGNATURES MUST BE IN BLUE INK <br />