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~- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />L To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence at the time <br />this application is filed, and located within 200 feet of the proposed affected 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.R.S.; <br />3. As the applicandoperator, I do not have any extraction/exploration operations in the State of Colorado 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.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C,R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction ojConstruction Materials. Any alteration or modification ofthis form shall result in voiding any <br />permit issued on the altered ar modified jorm and subject the operator !o cease and desist orders and civil pena/ties jor operating <br />without a permit pursuant to section 34-32-123, C.R.S. <br />Signed and dated this \\'~'~'. day of S ENV AQ `J~ d OAS <br />~.o~..~<..e...1~4 /[1oYt2rzo/s ~ot~ If Corporation Attest (Sea <br />ApplicanUOperator or Compancy Name <br />Signed: J Signed: <br />Corporate Secretary or Equivalent <br />Title: u SCE Q RES ~DE„h1'C Town/City/County Clerk <br />State of ~L L /tl/DIS' ) <br />ss. <br />County of Cloo,~' ~ <br />The foregoing instrument was acknowledged before me this //~ day of u.t.Qti` , aUDu~ <br />-, by ~ogEPN f SuM as VISE ~RESIdEnJT ofLYO,yT1AJEAITAL MAT~21RCSCo,r?~P <br />~~_ w • t twKuc~c.yK- <br />OFFICIAL SEAL Notary Public ~ <br />ANNENIARIE B NUSEKABEL <br />koTARYFl1BUC•STATEOFM1LN018 g-aa -o S <br />~'COM~SSIONE1fPIliES~1/120! My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />M:\miv~sAare\vsforms\Coustruaion 112.doo (0]/28/2004) <br />