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Certification: <br />-6- <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. All necessary approvals from local government have been applied for (Section 34-32.5-110(1)(a)(VIlI). <br />2. 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 azea have been identified in this application <br />(Section 34-32.5-115(4)(e), C.R.S J. (NOTE: For I l0 operations, the affected area includes all lands delineated by the <br />permit boundary.) <br />3. No mining operation will be located on lands where such operations aze prohibited by law (Section <br />34-32.5-115(4)(4), C.R.SJ. <br />4. As the applicanUopemtor, I do not have any mining/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.). <br />5. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein aze punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-I10,C R.S, of the <br />Colorado Land Reclamation Act for the Extraction of Construction Materials. Any aheratlan or modification ojthis jorm <br />shaU-esuU in voiding any permit issued on the altered or modified forne and subject the operator to cease and desist orders <br />and civil penalties for operating without a permit pursuant to section 34-32-123, C.R.S. <br />Signed and dated this ~}~ day of <br />Cheyenne County <br />ApplicanUOpemtor <br />Signed; <br />Title: County Administrator <br />State of Colorado ) <br />ss. <br />County of Cheyenne 1 <br />2005 <br />If Corporation Attest (Seal) <br />Signed: ~- <br />~ow~it~/County Clerk <br />5/S/ ~~ ~~ <br />Ca6t~.e.-w.~.-cz~c~ @~ ~o S'. c7 <br />The foregoing trument was acknowledged before me this ~ day of <br />~~ /I /_Q <br />~by ~?~ii~.~w as (" of <br />~~^C~cc..{ L ~c~t~n ~ p/f <br />,.: - <br />~_ _-~ <br />.Nota Public <br />= , _ - = My Commission expires: S 0 <br />~~~ <br />SIGNAT'I112ES MUST.$E IN BLUE INK <br />