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~- <br />Certification: <br />As en authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements ofthe <br />following terms and conditions: <br />All necessary approvals from local government have been applied fbr (Section 34-32.5-110(1)(a)(VQI). <br />2. 'Fo tbe best of my knowledge, all significant, valuable attd petrttanent man-made shveture(s) inexistence at the time this <br />application is bled, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32,5-I lS(4)(e}, C.R.SJ. (MOTE: Fort 1 D operations, the affected area includes all lauds delineated by the permit <br />6oundary.l <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-115(4)(f), <br />C.R.S.). <br />4. As the applicanUoperator, I do not have any mining/exploration operations in the State of Colorado currently m violation of <br />dte provisions of the Colorado Land Reclamation Act for the Extraction ofConstmction Materials (Section 34-32.5-120, C.R S.}. <br />S. I understand that statements in the application aze being made under penalty ofperjuty and that false statements tttade herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />Thisform has been approved by the Mined Land Reclamation Raard pursuant to section 34-32.5-II Q C RS, ofthe Colorado Land <br />Reclamaxion Act far the F..ztracrian of Construction Materials. Any alteration or modifecodon ajtkrs jorm sfrall result in voiding <br />any permit issue4 ea tke uttered or modified form and subject tke operator to cease and desist orders and civR penalties for <br />operating without a permit pursuant to section 34-32.5 J.1~3, C.R.S. <br />Signed and dated this ` ~ day of <br />ApplicantiOperator <br />Signed: <br />Title: <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />TowniCity/Cotmty Clerk <br />State of 6t~1LIGM\0.i ) <br />0 ~ ) ss. <br />County of A) }jj nn,-,t. ) <br />The foregoing instrurrmeat was ac owledged before me this ~ C1+~ day of U~ v~ti - ~ ~~ , <br />c-~ ~- `~ <br />.r~,....a....~- \ <br />Sherry Pharoah -NOTARY PUBLIC ° ' `- t \'*~~~~' <br />'.JOtary Public <br />County of " :t, - ~~ State of <br />Albany ' - Wyoming uy Cotmrtission oxpires: ~~ ~ t o?ik~°! <br />MY Comm4~lon F~Ires: November 2t4 --""-"----_- _-- <br />SIGiVATURF~ iVIL•ST BE IN BLUE INK <br />M:rmin`sh;veivsfumslC:onstruction 10 (,\ppeoved OSit Ir20115) <br />