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-G- <br />As an authorized repreaetttative of the applicant, I hereby certify that the operation descnbedhas met the minimum requirements <br />of the following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 34-32.5-110(l)(a)(VIIl). <br />2. To the best of my knowledgc, all signiftcant, valuable and permanent man-made structure(s) in existence at the time <br />Uvis application is filed, and located within 200 feet of the proposed affected area have been identifted in this application <br />(Section 34-32.5-115(4)(e), C.RS.). (NC1TE: For 110 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 are prohibited by law (Section <br />34-32.5-115(4)0, C.R.S.). <br />4. As the applicant/operator, 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 fox the Extraction of Construction Materials <br />(Section 34-32.5-120, C.RS.). <br />5. I understand that statements in the application ere being made under penahy of perjury and that false statements <br />made hcreiia axe punishablc as a Class 1 misdemeanor pursuant to Section 18-S-S03, C.RS. 1954, <br />Tkts form has been appraved by tke 1Vltned Land Rectamation Board pursuant to section 34-31.5-1 XO,C.R.S., of tke <br />Colorado Land Reclamation for tits Exd~actton of Construction Materta/s. Any alteration ar mod~atbn of tkts form <br />skaR result in voiding anypermit Issued on Ike altered or modified form and subfect the operator ro cease and destst <br />orders and ctvR penalties for opetnting witkout a permit pursuant to section 34-32-123, C R.S. <br />Signed and datedthis --~-,r-- day of i`~ U S'~ ~~ { <br />-7l <br />/A®El2 (~Nri~vl^-S S,(~~p ~ c~-~z~l /~ L <br />Applicant/Operatar ~~ <br />Signed:~22d/~ _ <br />Cliyk~l~ <br />Title; (_,~ Gf/N iE /Z <br />State of (EJ~D/lj ct'd ) <br />as. <br />County of~2f/ L!lIL9 ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />TheTforegoing instrument was77acktwwledged before me this ~_ day of <br />~a~~av~' ~/arK /~ <br />./a _ <br />c.~. <br />by <br />~;••- •'v`/~~ Notary public ~ / <br />DEBRA R. MyCommisaionexpires: ~%~S~/~ <br />PONCHAK <br />wr.+mm~i ATURES BE IlV BLUE INK <br />wtwa,auA~aooitoros~zaoa) c~'_..._...•i;Q- <br /> <br />My Commission Expires 06J24106 <br />