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~~CEIV~® <br />~ - JAN ~ 12005 <br />Division of Minerals and Geelogp <br />an authorized representative of the applicant, T hereby certify that the operation describedhas metthe minimum requirements of <br />following terms and conditions: <br />1. To the best ofmy lmowledge, alt significant, valuable and permanent man-made structure(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 3432.5-115(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), C.RS.; - - <br />3. As the applicant/operator, I do not have auy extractionlexploratioa operations in the State of Colorado omreney 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.RS.) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty ofperjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. <br />This form has been approved by 8ie Mined Land Rec/ana4iox Board pursuant to section 34•-32.S:Il$CRS, of the Colorado Land <br />Rerlanration Adfor the F-zlrac4on ojCoxstrudiox htateriolt Any adteratum or mos&fiadion ofthis jorm s1+aII rerult in voidixg any <br />permit issued on tke altered or modijudform and subject the operator to cease axd desisrorders and civilpexatliesfor operaforgrvhliord <br />a permit pursuant to section 34-32-123, CRS <br />Signed and dated this ri L day of 3a,~ a AkX .1~0 5 <br />Lou-coAEnl Rt'n5 sronl~E CamAanlr <br />Applicant/f)perator or Company Name <br />If Corporation Attest (Seal) <br />Signed: ~d~,,~~+i'kt~" <br />Title: 1:,~1Ei_°.9L /79/l~t//1G6~', <br />State of CeLD~A p ~ 1 <br />} ss. <br />Cou~y of QD ~ z- D ~ OOL ) <br />TownlCity/County Clerk <br />The foregoing instrument was aclmowledged before the this ~~ day of ~`A~c9(.1A.2~ _ 2DDj _ by <br />rri~CHA~L LDu,NDN~~ as 6fr.1 mfl~Uf~~.~ of lak.~~fN 3eos STo;J~ ~,D, <br />~, ~~~~~ .~'. L9~Ic2.l~l/ <br />..- `; <br />Notary Public <br />... <br />` ~ ~' My Commission expires: / a2 - 02 7 ~ 7 <br />SIGNATURES MUST BE IN BLUE INK <br />Si fin/ A LL(1 /ll,c.~7 I~'J/ t-iG~}`] <br />Corporate Secretary or Equivalent <br />ae:~~~s~~ca~aian u2mo tmizsnooa) <br />