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~~c~r~o <br />APR'11:~ 2001 <br />_~_ , <br />DIViNOIt W Reclatn2tiW-. ~1 <br />Certification: Mh1111Q 8114 $8~ <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the <br />following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 3432.5-110(1)(a~VIII}. <br />2. To the best of my knowledge, all significant, valuable and permanent rrlan-made structure(s) in existence at the time this <br />application is filed, and located within 200 feet of die proposed affected area have been identified m this application <br />(Section 34-32.5-115(4)(e), C.R,S.). (NOTE: For 110 operations, the affected area includes all lands delineated by the permit <br />boundary.) <br />3. No mining operation will be located on lands when; such operations are prohibited by law (Section 3432.5-115(4)(f), <br />C.R.SJ. <br />4. As the applicartloperator, I do not have any rnining/explorarion operations in the State of Colorado cuaently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section 3432.5-120, C.R.S.). <br />5. 1 rmderstarrd that statements in the applicafioa are being made ender penahy ofperyuryand that false statements rrlade herein <br />are punishable as a Class 1 misdetircanor pursuant to Section 18-8-503, C.RS. 1984. <br />Thisjorm has been approved by theMinedland Ree/amoNon Bomd pursuant to section 34-32.5-JIO,CRS, oflheCalorado Land <br />Reclamation Act for the EztraMion ojConsmrdion Materials Any alteration or modiJlcation ojthis jotm shag resuh in voiding <br />any permi! issued on [he ahered or modified form and subject the operator [o cease and desist orders and civB penalties jor <br />operating without a permU pursuant to section 34-32.5-123, C.RS. <br />Signed and dated this~~ day of ~ ~ (, ~~~ <br />'a e~IP <br />ApplicanUOperator <br />Signed• ~j~ <br />Title: ~t.J~~~ <br />if Cotporatian Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />ToanJCity/County Clerk <br />State of ~ ICJ ~ ) <br />L ) ss. <br />Covnty of ~f'P-1~'1OY1 t~ ) <br />The foregoing instrument was acknowledged before me this ~ ~~ day of~__~_ , <br />~pp-7, by (~A.C-~ ~ 1C as b[.J Cl~' ~ of <br />My Cormnission expires: ~~f i 1 e dD~ a~o~ _. <br />~ zo~>LOl <br />:Ks~cx~ exphea aU~ <br />° SIGNATI7RES MUST BE [N BLUF, INK <br />M:~min'sharclGsfums`~.Qmswclionl 10 (Approved 05/11!1005) <br />