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i -_ ~ ` ''t ~ P"~'' <br />Certification: <br />y D(vlalon of t,-r~lr,nl. ifon, <br />Mininn ;and rii 10:Yy <br />As an authorized represrntative of the applicant, I hereby certify that the operation described has tit the minimum requirements of the <br />folhtwutg terms a~ conditions: <br />All necessary approvals from total government bare been applied for (Section 34-32.5-110(I)(a~ V [II). <br />2. To [he best of my latowledge, all significant, valuable and permanent ratan-made stmcttae(s} in existence at the time this <br />application is 61ed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section3432.5-] 15(4)(e), C.R.S.). {NOTE: Por 1 t0 operations, the affected area includes all lands delineated by the pemtit <br />boundary.) <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section 3432.5-115(4Mf), <br />C.R.SJ. <br />4. As the applicandopemtm, [ do not have any mining/exptoretion operations in the State of Colorado ntrtcnHy in violation of <br />the provisions of the Colorado [and Reclamation Act for the Extraction of Constmetion Materials (Section 3432.5-120, C.R.S.). <br />5. 1 unders~ttd that statertrents m the application are being made tinder penalty ofperjury a»d thaf false statenrvts made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18.5-503, C.R.S. 1984. <br />TkLsjorm kas brew approved bythe Mimed Land Reclamation Board pursuaruta section 3J-32.5-7 JO,C RS, oJthe Colorado Lard <br />Reclamation Act jar the F.xtracYion ojCansttuctton Materials My alteration or modifrcaftan ajthisjorm shat! rrsa/tin valdtng <br />any permit issued an the altered ar modified john sad subjeet the operator to tease and desist orders and avlt ptaalties jar <br />operating without a penrrit pursuant to aectinn 30-32.5-723, C.R.S <br />Signed and dated this ~^ day o~ /t() /l l~ q (~ / <br />ApplicanV~I`Op~'erator <br />Signed: /l~~ <br />Title: ~ ~ C F 1 (-e-S <br />State of ~.~~ t 1 U ,(.l'.l ~ ) <br />/~ 1 n ) >s. <br />Couniyof lA~r.1~)_.L4'p~.~lt ) <br />The f t <br />_, by <br />~.~'uKl 1 <br />instnunent was acirnowledged before me this 1 l Y~ __ day <br />1 <br />r.~:.- 3~ I~l (~l~ <br />Qtly t^artlrist=lc~atl ~~cr:ire, . _._ <br />as lJ'`1XJ V N' W/~-t~C_L ~ILU'_.. _. _.... of <br />~ X 1 ~o ~ ~ ~ ~ rfll , <br />Notary Public II r1 /~ <br />My Cormnission expires: o~ 1 I V <br />If Corporation Attest (Seal) <br />Signed: V `t-4ti~ <br />Corporate Secretary orEquivalent _ '`.~ <br />TowNCity'/County Clerk.';: <br />-"~_ <br />SIGNATURES MUST BE IN $LUE INK <br />M:tminlsharZrsfnrms.Gatstnxlian 110 (Appro~rd OYI tiI00~ <br />