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~J <br />- b - <br />Certification: <br /> <br />As an authorized representative of the applicant I hereby certify that the operation described has met the minimum requirements of the <br />following terms and conditions <br />All necessan 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 swcture(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-I l5(4)(e), C.R.S.). (NOTE: For l l0 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 Imv (Section 34-32.5-115(4)(f), C.RS.). <br />4. As the applicant/operator, l donor have any mining/prospecting operations in the State of Colorado currently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction of Conswction Materials (Section 34-32.5-120, C.R.S.). <br />5. 1 understand that statements in the application aze being made under penalty of perjury and that false statements made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS 1984. <br />Signed and dated this day of 6~_. <br />~~ ~ ~~ Q <br /> <br /> pplicant~ Aerator <br />J <br />Signed: <br /> <br />Title: <br />[f Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of GIG'rGlCi' ) <br />l ) ss. <br />County of C~U/Yllyl i 7 ) <br />Th aregoing instrument wa acknowledged before me this day of , ~L, by <br />as I.cJL/ <br />" Not ublic <br />My Commission expires: ~-~`~ - God <br />SIGNATURES MUST BE IN BLUE INK <br />M:VNIMSHARE\VSFORMS\2821COIO.APP 062'99 <br />