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RECEiVE® <br />Certification: <br />,. <br />As an authorized representative of the applicant, 1 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 far {Section 34-32.5-I 10(1)(a)(V Ill). <br />2. To the best of my Imowledge, all sigrificant, valuable and permanent man-made structwe(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 34-32.5-1 IS(4)(e), C.R.S.). (NOTE: For 110 operations, the affected azea includes aJJ lands delineated by the pem»t <br />botmdary.) <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-1 l5(4)(f), <br />C.R.S.). <br />applicanVoperator, 1 do not have any rniningiexploration operations in the State of Colorado currendy 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. 1 understand that statements in the application aze being made under penalty of perjtny and that false statements made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S_ 1984. <br />Thlsjorm has been approved by the Mined Land Reclamation Board pursuantto section 34-32.5-IIO,C.RS, ofJhe Cbforado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modifrcation of this form shall result in voiding <br />any permit issued on the a4ered or modified form and subject the operator to cease and desist orders and civil penalties for <br />operating without a permit pursuant to section 34-32.5-113, C.R.S. <br />Signed and dated this <br />ApplicanVOperator <br />aay of <br />If Corporation Attest (Seal) <br />Signed: / <br />~-~- Gu t~ <br />Title: <br />Signed: <br />OC7 2 4 2006 <br />Division ofa d Satety n <br />Mining <br />Corporate Secretary or Equivalent <br />Towrt~'Ciry/County Clerk <br />. ~ ` ) OFFICIAL SEAL <br />State of /~~ ,ra.~ MANDY BOGACZ <br />)ss. NOTARYPUBLIC-SlateofArizw, <br />Coun of .yy1~ ~ ~ MAfiICOPA000N7V <br />7' --c<<u~a..i.c+~-flEt~----) My Comm. Expires Nav. 14. 2009 I <br />'i'he 1"oregoing instmment was ackQnowledged before me this / 6jh day of ~ ~ , <br />r CQ, by _ (L7~ GZ _ as of <br />- ~~~ r GI~C~eh . <br />Notary P lic <br />hly Commission expires: _~_(~_~ <br />SIGNATURES MUST RE IN 8L[JE INK <br />SI ~min!sharc'vstbrtnriCon9WCtion 110 (Approved OSil1^--005) <br />