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RECE~ ~E~ <br />_ a _ OEC 2 p p0Q6 <br />Division <br />Certification: Mining and Sa e~ on, <br />As an authorised representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements <br />of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence at the time <br />this application is filed, and located within 200 feet oI'the proposed affected area have been identified in this application <br />(Section 34-32.5-115(4)(e), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicanUoperator, I do not have any extractioniexploration operations in the State of Colorado currently in <br />- _ violation of thu_proyisiQns of the Colorado Land Reclamation Act for the I:xtraction_of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Board•finding. - - ' ~ _- - --- ~ --- - <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein aze punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This jarm has been approved by the Mined Land Reclamation Board pursuant to ,section 34-32.5-712,C.RS., of the Colorado Land <br />Reclamation Actjor the F.xtractian aJConstruction Materials. dny alteration or modification of thisform sleall result in voiding any <br />permit issued on [he altered or modified farm and subjec[ [he operator to cease and desist orders and civil penalties jor operating <br />without a permit parsuaut to section 34-32.5-I23, C.RS. <br />Signed and dated this S day of QQee.~n 5P1` x006 <br />OId'CGYr/I( S4 CMVp Znc, /70/i (nt-,!w~ L~mr'Yattc'r <br />ApplicanUOperator or Company Name <br />Signed: <br />0~!'yFfa may [f Corporation Attest (Seal) <br />Signed: _ <br />Corporate Secretary or uivatent <br />Title: _~~~eC P/PSl0Pn7~ <br />State of C o /` a o ~ ) <br />ss. <br />Towtv'Ciry/County Clerk <br />County of ~' W 5 ~ j <br />The foregoing instrument was acknowledged before me this ___,5~_ day of _~~? ~?~nV1c r, ~~ <br />.lo~,bY-~ls~~_l-tayv,~.un~---as~ f~e '~..vi~' _of_121~c ~e SW row (NC• <br />~ bu u~,trd ~m,..rp,~r.ts o ~=~w,~y <br />d /°~ ~ <br />o~ •'• 4~p' • -••' ~"9.~ Notary Public <br />„ .•. •. •. <br />v f G O •: ~ . .. . <br />:T• Y J ...'.. <br />c w t A~ My Commission expires: a r"J 3 CJO~`•' •' <br />20•, ti~~ - - . <br />•°~.,9t,~'•••••'•'•p~~ ~~ SIGNATLiRES MUST BE IN BLL;E INK ~ ~~°`f '•}~:~; <br />0 ~~ <br />M:~nm~~share$r(ppnZ~C0re,rvab6112-anc {Apprmcd OSll U2W5) - - - - - - - - <br />rrlrluNr• <br />