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RECEilfED <br />- s - MAR ~ 3.2006 <br />Certification: Division of Minerals nod Geology <br />As an authorized representative of the applicant, I hereby certify that the operation described has met theminimum requirements of <br />the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and pemtanentman-made structure(s) in existence at the time this <br />application is filed, and located within 200 feet of the proposed afYected area have been identified in this application <br />(Section 34-32.5-115(4)(e), C.R.S.). <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 applicanUoperator, I do not have any extraction/explora[ion operations in the State of Coloredo currently 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 penally ofperjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Thin jorm has been approved by the Mined Land Reclamation Board pursuant to section 34-31.5-112,C.RS, ojrhe Colorado Land <br />Reclamation Adjor dre Extraction ojConstrurtron Materials. Any alteration or modification afdris jorm shaUresulr rn voiding any <br />permit issued onlhe offered or modifiedjorm anti subject the operator to cease and desist orders andcivil pena6Yes joy operotngx$bout <br />a permit pursuant to section 94--32.5-123, CRS. <br />Signed and dated this ~ day of ~QrC h Z o b ~ <br />Name <br />. f4-~ <br />~~, f <br />Title: /~~~E7,r%J~1.'~ <br />,- ,F, <br />F~~ _ <br />Stale of ~C.D~DYA,~~ ) <br />County of :.~ LM <br />If Corporation Attest (Seal) <br />Signed:~~ ~ _ ~ ~C~U./~ <br />Corporate Secre or Equiv t <br />Town/City/County Ckrk <br />The foregoing instrument was acknowledged before me this ~ i day of ~ ~i a`~r.~ ;~ D O,(p , <br />by ~t-+--+c~~r~- as ~/'ZSia~r'..n~f" of ~Pl`G »5`t~' ~~OnS~i'kA,t4;v7t <br />a1iElul-e/ S~'c~giiS~ <br />Notary Public <br />My Commission expires: ~~ ~j ' o~O~ Q <br />SIGNATURES MUST BE IN BLUE INK <br />M:~~~wto~,~caw~,~~ ~ iz.a~ tnrarovea osn uxoos> <br />