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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 requvements of the <br />following terms and conditions: <br />1. All necessary approvals from local government have been applied for (Section 34-32.5-110(1)(a)(VIII). <br />2. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence a[ [he time this <br />application is filed, and located within 200 feet of the proposed affected area have been identified in [his application <br />(Section 34-32.5-115(4)(e), C.R.S.). (NOTE: Fort 10 operations, the affected area includes all lands delineated by the permit <br />boundary.) <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 [he applicanUoperator, I donot have any mining/exploration operations in the State of Colorado currently in violation of <br />the provisions of the Colorado Land Acclamation Act for the Extraction of Construction Materials (Searion 34-32.5-120, C.R.S.). <br />5. I understand [hat statements m the application are being made under penalty of perjury and that Else statements made herein <br />are punishable as a Class t misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />Thisjorm has been approved by the Mined Land Reclamation Board pursuant to section 34425-IIO,CR.S, oftheCo%rado Land <br />Reclamation Actjor theExtraclion ojConslntetion MaterlaLc Arty alteration or mad cation ojth8form shall resuhtn vohfingarry <br />permit Issued on the altered or modified jarm and subjeM the operator to cease and desist orders and civil penalties jor operatitrg <br />without a perndt pursuant to section 34-32.5-123, GIZS. T <br />Sipped and dated this ~_ da~~ of ) u nJ c 2 ~~ <br />i~! If Corporation Attest (~eal),.^` ~ '~, <br />~," i ~" <br />A IicanVO emtor ~ r -„ ~- = s <br />PP P ~~ J) c 2 ,~--- ~ - <br />Signed: ~ W~~ Signed'~~_tl~„ <br />a- --y <br />I ~~ <br />~J Corporate Secretary'Or Egniaate,n ~~ <br />Title: ~[t~+.~1jO.xIT Town/CitylCountyCfefB <br />State of l-c~CdQR ~n ) <br />Cotmh of ~EZ'!"A ) <br />The foregoing instrument was acknowledged before me this ~` n_t da~~ of ~t- -~ + <br />da~2.b~ ~la.vt f.JL\~S anc~ Ltlltav~ ta)e.((S as YYrStc~w~~ a-nR 7[Lre~tJLVV of <br />Q~Me-rc~, inc. . <br />'l~Y•~~~ <br />~~•' ••~~[t Notary Public <br />~• = M}' Commission expires: ~~ ~ a ~ '-1/ 4~ <br />~g <br />BLUE INK <br />M:1minlshnrelvsformslConstruction] 10 (Approved 0511 <br />