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_g- <br />Certlftcati~~t <br />As an authorized representative ofthe applicant, I hereby certify that the opetaUon described has met the rrrinimum requirements <br />of the following toms and conditions: <br />1. To the best of my knowledge, all significant, valuable and pemm~ent man-made structure(s) in existence at the Nme <br />this application is filed, and located tvithin 200 feet of the proposed affected area have been identified in this application <br />(Section 3432.5-1 IS(4}(e), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 3432.5-i 1S(4xf), C.R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State of Colorado cum7rtly in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Crntstrucdan Materials <br />(Section 3432.5-120, C.R.S.) as determined through a 13oatd Ending. <br />4. I understand that statements in Ute application are being made under penalty of perjury and that False statements <br />made herein are punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to sectfon 34-31.5-IIZ,C.2S, oftbe Colorado Land <br />ReelamationActfortheE,rtracHonofConsrructfonMatetVals. Aayaltarot/anormodiJlcadunaJthivJormahollrestdtinvoidhrgany <br />permU issued oa the akered ar modified form and sabjec[ the operator to ceaae and desbt orders aad civil penaUles jar operating <br />wUhoat apermirpnrsnanr to section 34-32.5-123, C.RS <br />Signed and dated this 2 2 day of <br />T,i nr~o t n Cnnn+v <br />ApplicanUOperator or Company Name <br />2007 <br />If Corporation Attest (Seal) <br />Signed: ~l ,-- ~~ ~t. M tti~sr~-' <br />Kenneth Morrison <br />Title: Land Use Administrator <br />State of ~'-~~araao ) <br />ss. <br />County of ~- ~ w~ ~-. 1 <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this ~.Z'"`" ~ day of J w,ci , <br />7_0~, by Ke,~.....~.~ rnt,~ s.p-~. _ as t....u. Pc~w.; v.: si-r-l-e-i of ~.:.-. ~,\.,. ~._..~~ <br />' Notary public <br />My Commission expires: ~ _ z~ ~-w,9 <br />- SIGNATURES MUST BE [N BLUF. INK <br />M:Vru~+LS>urcl.srmad['avnw[ion 112Rac (Appro,Yd US/11:20113) <br />