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RECEIVED <br />- ~ - OCT 19 2004 <br />Certification: Division of Minarets and Geology <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements 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 ofthe proposed affected area have been identified in this application <br />(Section 3432.5-1 I5(4)(e), C.R.S.). <br />2. No mining operation will be located on lands where such operations aze prohibited by law <br />(Section 34-32.5-115(4)(1), C.R.S.; <br />3. As the applicanUoperator, I do not have any extraction/exploration operatons inthe State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction 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 are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This jorm has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-I12,C.RS., of the Colorado Land <br />Reclamation Act jor the Extraction ojConstruction Materials. Any alteration or modification ojthis jorm she/! result in voiding any <br />permit issued on the ahered or modified jorm and subject the operator to cease and desist orders and civil penalties jor operating <br />without a perrrdt pursuant to section 34-32-723, GRS <br />Signed and dated this ~ {"t day of ~'~ei,/ `~ <br />-I-~~k~.nS ~an~ n.~S~yal 4 ILLc - <br />Ap anUOperator or Company Name <br />Signed: ~~p~'t (% ~ ~ %t~ ~~ <br />Title: <br />State of <br />ss. <br />County of ~1 MPnr 1 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The fopregoing instru/m~ ant was acknowledged before me this ~; day of t~/C fCG,6!/ , ~' a® <br />>by ~61Gf e~lffivg~e,J 7~ as A R C of~igt!, P~A/NS SA,vd A,/~ <br />Notary Public - - __ <br />My Commission expires:- ~/~`- o~~ad0~ <br />CLC <br />SIGNATURES MUST BE IN BLUE INK <br />M:~min~snae~nromrs\cotetructlon i iz.m~ imaenooa> <br />