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-~- <br />Certification: <br />As an authorized representative of the applicant, l hereby certify that the operation described has met the minimum requirements of the <br />fotlowing terms and conditions: <br />All necessary approvals Crom local goverrmumt have been applied for (Section 34-32.5-I 10(1)(axVlIl). <br />2. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence at the 6me 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(4xe), C.R.S J. (NOTE: For 110 operations, the affected area includes all lands delineated by the 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(4xf), <br />C.R.S.). <br />4. As the applicanboperator, I do not have any mining/exploration operations in the State of Colorado currently in violation of <br />the provisions of the Colorado Land Reclamation Ac[ for the Extraction of Constntction Materials (Section 34-32.5-I2Q C.RS.). <br />5. I understand that statements in the application are being made under penalty ofperjury and that false statements made herein <br />are punishable as a Class 1 misderrxanor pursuant to Section 18-8-503, C.RS. 1984. <br />Thlsform has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-I10,C.RS, ofthe Colorado Land <br />Reclarrradon Actjor the F-xtraedon of Constraction Materials. Any alteration or modiJicadon ajthis form shall resod in voiding <br />any permit issued on the altered or modjfied form and subject fhe operator to cease and desist orders and civil penalties for <br />operating without a permit pursuant to section 34-31.5-723, CRS <br />Signed and dated this .?lu ~ day of `~~-n-/im.,N/1 ~FJU' L" <br />Ritcheys' Redi-Mix Concrete, Inc. <br />Applicant/Operator <br />Signed: L `~..~~y <br />Title: thmer 7t <br />If Corporation Attest (Seal) <br />Sign <br />C iporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of Colorado <br />ss. <br />County of Phillips ) <br />'Che foregoing instrument was acknowledged before me this ~ ~ lilt day of ~L°/-~T~~l~ ~ 2. ~~ ~P , <br />-•bY Jerry Ritchey as Owner/Ooerator of <br />Ritcheys' Redi-Mix Concrete, Inc. <br />Notary Public l '~ <br />My Commission expires: 2-22--08 ~ ~ ~ - <br />-i <br />~;~. <br />S[GNATi1RES MfTS'I' BE IN BLUE INK ~ I "~ <br />M:~minkharelvstixnalConswclinn 110 (ApprtrveJ o5/f 12 WS) <br />