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~- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements ofthe <br />following terms and conditions: <br />1. All necessary approvals from local govemmen[ 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 stmcmre(s) in existence a[ the time this <br />application is filed, and located within 200 fee[ of the proposed affected area have been identified in [his application <br />(Section 34-32.5-115(4)(e), C.R.SJ. (NOTE: For l10 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-I15(4)(f), <br />C.R.S.). <br />4. As the applicantlopera[or, I do no[ have any mining/exploration operations in the Slate of Colorado currently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section 34-32.5-120, C.R.S.). <br />5. I understand that statements in the application aze being made under penalty ofperjury and [hat false statements made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />This jarm has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-110,C.R.S., ojthe Colorado Land <br />Reclamation Act jar the Extraction ojConstructton Materials. Any alteration or modification ajthis jarm shall result in voiding any <br />permit issued on the altered or modifred jarm and subject the operator to cease and desist orders and civil penalties jar operating <br />without a permitpursuant to section 34-32.5-113, C.R.S. <br />~Wl `^ <br />Signed and dated [his ~ day ot'~~f~PVY\ 11C / ~75 <br />/' i <br />\~ l ~.11J ~y .„°`""°"1'P~q,`rporation Attest (Seal) <br />Applic dOperator ~ GppSON CMG <br />~~~~ <br />~~ ~ <br />Signed: _ *= CST ~ 3~ne <br />/~ -7L,_,Li_L orj~orate Secretary or Equivalent <br />Title: l l~l 1~y ~ ~~~~5~~'1}-T17~ •'•~%1 ~ M,/ Town/City aunty Clerk <br />"~COCORA~~ ~p+` <br />/I ,..,.~.......• <br />State of l O~O~,Rd(~ ) <br />I ) ss <br />County of .-I"C~YSOYI ) <br />The foregoing in^str~ument wasnacknowledged before me this _7U" <br />I;`~', by ~.11 Y~ 7~~Ol.l 0-t,C ~C~ as _ <br />,~i~.~R/Jn ~C;I~n~. <br />~~o Tq9 <br />q' ,oG ~~ <br />c~~~..QLIC..~ <br />SIGNATU <br />day of <br />of <br />Commission expires: ~ ~"~ 9 ~~ <br />INK <br />M'Unin\share\vsforms\COnstru<tion 110 (Approved OS/1 I /2005) <br />