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<br />,R~~~~VED <br />- ~ - MAY 23 ?!m6 <br />Certification: Division of Mfaerala anp fieolagp <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements 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 petmanentman-made stmcture(s) in existence at the time this <br />application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-11S(4)(e), C.R.S.). (NOTE: For 1 ] 0 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 34-32.5-11S(4)(f), <br />C.R.S.). <br />4. As the applicant/operator, I donot have any mining/exploration operations in [he State of Colorado currently in violation of <br />the provisions of the Colorado L"and Reclatnatroti Act for the Extraction of Constmction Materials (Section 34-32,5-120, C.R.S.). <br />S. I understand that statements in the application are being made under penalty of perjury and that false statements made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32. S-]]O,C.R.S., ofthe Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification ofthis form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Ad <br />Signed and dated this da day of a0d <br />t29ARK I~oKBS - ~tttittt.. {~o.v'~v{c~s{~{.•I° <br />Qpplicant/Operator <br />Signed:~~~ <br />Titie: (P3s~ttlw. - ~~ <br />Slate of t.O-(rB-'lo zd'-l/' ) <br />County of ~Z71-d~-9~o~J. ) <br />hd <br />If Cotporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instmmnent was acknowledged before me this ~ o~. day of ~D~_, <br />_, by 1'1'~t.l~ ~~ as (~J ~s-s-cQJt ~ - . ~ . of <br />{•,{\UTl:ill iftfllJJJJJJ,, \~~ ~\ ~~ ~ .~ <br />rb ~~.~~ 1.,~j\<,i'~ Notary Public <br />~ n ~~ ••'~' My Commission expires: D to ' ~ 7 ~a <br />~ 0 p ~~~ <br />t ~ ;'..~. <br />~~,,.:=•' }. ; SIGNATURES MUST BE IN BLUE INK <br />d <br />,.,~~ ..<<o•~ <br />$siS~atMVStdm{s\Constructionl 10 (Approved 05/11/2005) <br />