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~- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimtun requirements of the <br />following terms and conditions: <br />1. All necessary 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 structure(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-I15(4}(e), C.R.S.). (NOTE: For 110 operntions, the affected area includes att lands delineated by the permit <br />boundary.) <br />3. No mining operation will be located on ]ands where such operations are prohibited by law (Section 34-32.5-115(4)(f), <br />C.R.S.). <br />4. As the applicanUoperntot, I do not have any mining exploration operations in the Stale of Colorado currently in violation of <br />[he provisions of the Colorndo Land Reclaroa[ion Act for the F.xirnction of Constmction Materials (Section 34-32.5-120, C.R,S.). <br />5. I understand that statements in the application are being made under penalty of perjury and that false statements made herein <br />are punishable as a Class 1 misdemeanor purstant to Section 18-8-503, C.R.S. 1984. <br />Thrs form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-IlO,GRS, ofthe Cnlorada Land <br />ReclamationAdfortheEm^actianafConstructionMaterials. Any alterationormodificafionofthisformshaAresuUinvoidingany <br />permit issued an the akered or modified form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-32.5-123, C.RS. <br />Signed and dated this ~C/ ~ day of (i/.L((f-GGdC.~ U r~r~J`~ <br />~ ~. <br />Title: ~~ t"" S' FitM~. <br />The foregoing i strument was acknowledgedy fore me this ~ day of , <br />a~ by ~ as /,~_~~~~(~ ~.vNa,Q.O/.v~L P~f Hof <br />~a~: Bfe. ,, ~ <br />NOTARY <br />-a- <br />My Commission expires: 7-`~0 ar~0 O <br />My Commission fspintApril 18,1088 <br />SIGNATURES MUST BE UV BLUE INK <br />M:\minlshare\vsformslConswctionl l0 (Approved OS/1 IR005) <br />State of G/X~) 4/`C~-1)J-~!fl~,/~ ) <br />County of ~i(/~~(~' ) ss. <br />1 <br />