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RECEIVE® <br />Certification: <br />OCT 2 4 2006 <br />~. <br />Division of Reclamation, <br />Mining and Safety <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the ttunimtun requirements of the <br />following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 34-32.5-1 10(!)(aj(Vlll). <br />Z. To the best of my knowledge, ail significant, valuable and permanent man-made smremre(s) in existence 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-I 15(4)(e), C.R.S.). (\OTE: For 110 operations, the affected area includes all lauds delineated by the pemtit <br />boundary.) <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-115(4)(1), <br />C.R.S.). <br />applicanVoperator, t do not have any mvtinglexploration operations in the State of Colorado currently in violation of <br />provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section 34-32.5-120, C.R.S.). <br />5. I understand that statements in the application are being made under penalty of perjury and that false statements made herein <br />are punishable as a Class I misdemeanor pursuant to Section t8-6-503, C.R.S. 1984. <br />7Y+ls jorm has been approved by the Mined Land Reclamation Board pursuant to .section 34-31.5-110.C.RS, ojthe Cotorado Land <br />Reclamation Act for the Extraction ojConstruction Materials. Any alteration or modification ojthlsjarm shall result in voiding <br />any permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penaltfes for <br />operating a•rrhoat a permit pursuant to sectron 34-32.5-113, C.R.S. <br />Signed and dated this <br />day of <br />ApplicanVOperator <br />Signed: <br />vU <br />Title: (f(qd./ <br />if Corporation Arrest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Toun/City/County Clerk <br />OFRCfA1 SEAL <br />State of (.(%1.!'ZO/IA_~ ) MANDY BOGACZ <br />ss. NOTALi'y PUBLIC - State of Adzu:, <br />County of,,p_/Q~__) My Comm. IFxpuesCAbvNt4. 2009 i <br />'fhe foregoing instrument was ac~kQQno~~w+edged before me this / L sh day of ~~ uwi) , <br />~, by (Oa C.Z _ as of <br />-' lit-~.,fvrGl~~elt . <br />tiotary P tic / // ~/~ <br />bty Commission expires: _~ (L[~~~L~ <br />SICNATLJRF.S MUST RE IN BLUE INK <br />\t ~min`sharch'sturms:C'onstmction 110 (Approved O5~ I I ?005) <br />