PERMFILE54153

• Permit No: M2004026
• IBM Index Class Name: Permit File
• Doc Date: 4/21/2004
• Doc Name: Signature Page
• From: LJ Development
• To: DMG
• Media Type: D
• Archive: No

~or~'~ l.5 Tx~'e~,;P-~r1F Ines ~~- ~~~;~G~~~
~ Zoa~ n~1o '' APR 2 1 2004 ,~
C.ertiscfltion:
Division of Miner Is
As an authorized r+epraentetive of tlr: sppGcany I hereby «rtify that the operation described bas max t0 BnA
requirem~mts of the fotlowvrg teTmv and condioona:
1. To the best of my Imowledge. aU significant, valuable and permeaeat urea-made swcdce(s) is existalce at the time
this application is ffiad, and located within 2110 feet of tlu proposed affected area have been identified is this application
(Satiaa 3432.5-115(4xe), C.RS.).
2. No mining oporadco will be located m holds where such operations ale prohibited Iry law (Sacxion
3432.5-115(4Xf), CAS.;
3. As the aipplica~/operator, I do mt have any extractiadexploratiam operations in the State of Colorado cutrmtly in
violation of dta pnoviseaos of the Colorado t.ead RerJamatiao Ad far the FxUactian of CAautlwKien Materials (Section
3432.5-120, CAS.) as datamined t6roagh a Bond finding.
4. I underataod that statements m the applicatam are being made under penalty of perjury and that false statements
made herein are puoiabable as a Chess I miadenroaoor pursuant to Section 1 &8-503, C.RS.
8~
Signed and dated this
LEONE SAND AND GRAVEL, LLC
day of ~ ~ r~ 1 Od 7` .
Applicam/Opeaator aCompany Name
C
Signed:
Title: r~-~~„ ~a~ _
State of `-1J"1-~~ U
ss.
Caumy
The foregoing i~htmoent was admowledgod before me this O ~ day of __ ~~~~U ~" by
--_ erg - of -
BERRIARD J. GOGXF,:~,s;.
touMy dark & Records'
P. O. Box i 15
TeMidad, CO 81092
If Corporation Attest (Seat)
~. Y:iS1".,Fa,il~,~ ~R=t Ry.~J r.~
$Igaed:
Corporate Secretary a' F.tpl 8 i l •i'1~
Town/City/Comfy Clerk
~~ ~~~ ~~~
f`
Mom 112doe (IWIS/lWl)
C`
~s
',`••
Notary public ~~ ~?7/,~ ~
My Commission `ocpites~~/"`-f~m`-~Q ~
SIGNATURES MUST BE IN BLUE INK

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