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7- <br />CerNRcatIon: <br />As an authorized representative of the applicant, I hereby certify that the operation descn'bed has met the rnininaan requirements ofthe <br />following terms and conditions: <br />1. All necessary approvals from local govermnent have been applied for (Section 34-32.5-110(1)(a)(VIII). <br />2. To the best of my knowledge, all significant, valuable and pemlanentman-made stntcture(s) inexistence at the time this <br />application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-115(4xe), C.R.S.). (NOTE: For 110 operations, the affected area includes all leads delineated by tbe permit <br />boundary.) <br />3. No mining operation will be located on lands where such operations are prohrbited by Ltw (Section 34-32.S-11S(4)(t), <br />C.R.S.). <br />4. As the applicanUoperator, I donut have any mining/exploration operations in the State of Colorado ennently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction ofConstmctionMaterials (Section 3432.5-120, C1tS.). <br />5. I understand that statements in the application are being made under penaltyofpetjury aml that false statements made herein <br />are punishable as a Class 1 misdemeanor pursuavt to Section 18-8-503, C.R.S. 1984. <br />ThLsform has been approved by theMined Land Reclamation Board pursuantto section 34-32.5-//0,C.RS, ojthe Colorado Land <br />Redamation Ad jor the F.rrtrecdon ojConstruction Materials Any alteration or madiJTcation ojthis jorm shall resuh in voiding <br />any permk issued on the ahered or modiJkd form and subject the operator to cease and desist orders and civJ[ penalties jor <br />operating wBhaut a penrrrt pursuant to section 34-31.5-123, C.RS .. ~ ..:... . <br />Signed and dated this <br />day of <br />Clyde and Marie Couch If Corporation Attest (Seal) <br />Applicant/Operator ~ <br />Signed: igmd: <br />Corporate Secretary or Equivalent <br />Title: (tamer Town/Ciry/County Clerk <br />0 <br />a <br />T <br />State of 1 <br />ss. <br />County of 1 <br />The foregoing instrument was acknowledged before rrx this <br />by Clyde Couch <br />day of <br />•:,~- <br />Notary Public <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />M:MinlsharelvsfonnslConstruction l i 0 (Approved OS/1 (/2005) <br />