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04/30/2005 08:42 <br /> <br />1970?'253303 <br />GRAND rJOUNTY 2'ON?NG <br />_ ~ _ ~ ~;= p~ 2 ~ 2005 <br />PAGE 01 <br />yv,-lags-olgCL} <br />Certification: u"`"'~ "-~~~ ~ ~ j~(,( <br />As an authorized representative of the applicant, I hereby txrtify that the operation described has met the min;ratnm requirements of <br />the following Corms and conditions: <br />1. Te the best cf my knowledge, all significant, valuable and pemtanent nano-made structure(s) in existexe ai the limo U:is <br />application is filed, and loeatod within 200 feet of she proposed a$ec:ed area have been identified in this application <br />(Section 34-32.5-115(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operations are prohibiud by law <br />(Section 34-32.5.115(4)(1), C.R.5,; <br />3. As the appficanUoperator, I do not have any extractionlexploration operations in the State of Colorado currently s <br />violation a£ the provisions of. Lhe Colarado band Reclamation Act for the Extaction of Construction P+tatcrials <br />(Section 34-32.5-120; C.R.S:) sa dctermincd~ttrrcugh a Hoard finding.......... . <br />4. I understaud that statements in the application are bcsg made under penalty of perjury and that false statements made <br />herein ere pt:rrislrable as a Class 1 misdemeanor ptusuant to Section 18-g-503, C.RS. <br />This jorm has been approved by thelifined Land Reclamation 9aard pursuant to section 3d-31.5-117,C.ICS., ajthe Colorado Land <br />Reclamation Ad,for W r E~aaion of Consbucdon Materials, Arty aYerafion or modlfuatian of this form shag result in voidi:g ar. v <br />permit Irtu¢d on the altei¢d or modijiedjorm sarrdsabjed the op¢raror m cease and desist orders and csvil penalties jot aperaPreg w7khnut <br />a permit pursuant ro sa~ion 34.3T-123, CR.S. <br />Signed and dated this ~~ day of ~~~M4~- ~~~_. <br />G~r.ol t;'rccvP! <br />ApplicanUOperator or Company Name <br />Signed: <br />Ti1c: (~WV1£1^ utt~ {~pera~Or <br />State of ~~9-~R/~4}-~.-C~ ) <br />) 99. <br />County of _~ e__~'x~ ) <br />The foregoing instrument was acknowledged before me this <br />day of <br />~ by <br />.. J........:_~_...._........ <br />LEE ANN GLAUGH i ER ~~ ~' ~~'~' <br />~~vv~NOTARY PUBIC < Notary Public <br />STATE OF COLORADO d <br />w, yy <br />I~iy Corr~TSalor 6xclres o5; ;Lc ~~n:f~ t~fy Commisaiois expires: S ~~ ~ T~ <br />SIGNATURES MUST BE IN BLUE INK <br />If CorporaCiott Attest (5ea11 <br />Signed' <br />Corpo: ate Secretary nr Equivalent <br />TownlCity/County Clerk <br />M'~oieVlua\wrarmi`.Cmaeuetlon l:2 Gx (o7RV200g1 <br />