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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 />1. 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 ofthe 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 applicant/operator, I do not have any extraction/explorationoperations inthe State ofColorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-] 20, 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 ]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 jor the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant to section 34-32-123, C.R.S. <br />Signed and dated this day of NOVEMBER 2004 <br />JACKSON COUNTY ROAD AND BRIDGE <br />ApplicanUOperator or Company Name <br />Signed: <br />Title: CHAIRMAN <br />State of COLORADO ) <br />ss. <br />County of JACKSON ) <br />If Corporation Attest (Seal) <br />Signed: (ip~LYit ~~c-~-.-- <br />Corporate:Secretary or Equivalent <br />Town/City/County Clerk <br />_ ~c <br />:; v~ <br />The foregoing instrument was acknowledged before me this day of November , 2004 <br />_ by Richard F. Wyatt as <br />My Commission expires: ~~ <br />SIGNATURES MUST BE IN BLUE INK <br />Chairman of Board of Counri Commissioners <br />Notary Publ c <br />My Commiuion Expires fi~2812006 <br />