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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 ofthe 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 of [he 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 applicanUoperator, I do not haveany extraction/exploration operations in the State ofColorado currently in <br />violation of the provisions of the Colomdo Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Boazd 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 jorm has been approved by [Ne Mined Land Reclamation Board pursuant to section 34-31.5-771,C.R.S., ojthe Colorado Land <br />Reclamation Act jot the F_xtraMion ojConstruction Materials. Any alteration or modifcation ojthis jorm shall result in voiding any <br />permit issued on the altered ar modified jorm and subject the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant to section 34-32-113, C.R.S. <br />Signed and dated this 1 S day of NOVEf~ffiER <br />2004 <br />SW TKO JOINT VENTDRE, LLC <br />ApplicanUOj~pJera~to~r o~rjjCompany Name !~!~ L /A <br />Signed: ~/~C~~^' `~-i ~ v~~'a~~ <br />MARRD. BELL, ..~'~._:~~ ""/ <br />Title: MANAGER <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Cletk <br />State of COLORADO <br />ss. <br />County of ARAPAHOE ) <br />The foregoing instrument was acknowledged before me this _ <br />by MARK D. CAMPBELL as MANAGER <br />~~ day of NOVF.I~ffiER 2004 <br />of SW TKO JOINT VENT[TRE, LLC <br />NOTARY PUBLIC ~jr~r~c ~ ~~y~ <br />STATE OF COLORADO Notary Public ~~//,n, <br />AMANDA L MAZE My Commission expires: / V1 <br />SIGNATURES MUST BE IN BLUE INK <br />M.\wn\share\vsiomss\Conswaion ll2.dw (0']RSI2004) <br />