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• Certification: <br />-~- <br />As an authorized representative of the applica»f, l hereby certify that the operation described has met the minimt_tm requirements ofthe <br />foliowing terms and conditions: <br />1. Atl necessary approvals from local govenunen[ have been applied for (Section 34-32.5-I 10(1)(axV11I). <br />2. fo the best of my knowledge, all significant, valuable and permanent man-made stttrcture(s) in existence at the time this <br />application is fded, and located within 200 feet of the proposed afFected area have been identified m this application <br />(See[inn 34-32.5-115(4xe), C.R,S,). (NOTE: For 110 operations, the af2ected area inchtdes all lands delineated by the permit <br />boundary.) <br />3. No trilning operation wit! be located nn lands where such operations are prohibited by law (Section 34-32.5-115(4)(1), <br />C.R.SJ. <br />4. As the applicanLbpemtor, t do not have any nrininglexploration operations in the State of Colorado currently in violation of <br />the provisions of fire Colorado I-and Reclamation Act for the Extraction ofConstruction Materials (Section 34-32.5-12Q C.R.S.). <br />5. (understand that statements in the application are being made under penalty ofperjrny and that false staierta;nts made herein <br />are punishable as a Class 1 arisdemeannr pursuant to Section 18-8-503, G,R.S. 198d. <br />This form has been approved by the Mined Land Redamation Board pursuant to srctfax 34-32.5-11 D,CR.S, ajthe Cbfarado Land <br />Rrefamation Att for the Extraction of C0I1Sfraet/Ofl Materials. Any alteration or tnodijecoiion ojthis Joan shall result in voiding <br />pny permit issued on the ordered or modifred foray and subject the operaror to cease gad desist orders and civU penaftfes for <br />operaffng without a permit pursuant !u section 34-32.5-J2/3, C.R.S. <br />)J~ ~J a.rtutt-r o2GD~ <br />Signed and dated this day of `~ , <br />• <br />Mullett Excavating. L.L.C. <br />Applicanv'Operator <br />Sigcec~i~ <br />on Mullett <br />Title <br />Slatc of C <br />55. <br />County of Custer _~) <br />The foregoing instrument was acknowledged before me this i a ~ <br />__, by Myron Mullett as _ <br />Mullett Excavating. L.L,C. <br /> <br />rr <br />., <br />,r;" . _ ~, <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secrernry or Equivalent <br />TowniCityiCounty Clerk <br />`~4 v-, <br />". <br />day of ~a.r~.wa."-~-~ -~ r- .s- ~ ~ j~. <br />Notary P tic. <br />bi 1r} retoro <br />My Corrnnission expires: _ <br />STGNATt.1RE5 MLi5'1' BF, IN BI-UE INK <br />M:`spin;r'h;m~`vsfumvs'.Cm~stn,cfion I IO (Appnnul OS%I Ii2005) <br />