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- 6 - RECEeVED <br />Certification: ,, CC <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the J~6rHr~ements <br />of the following terms and conditions: DiYisioo of Minerals and ceaiogy <br />1. All necessary approvals from local government have been applied for (Section 34-32.5-110(I)(a)(VIII). <br />2. 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 the proposed affected azea have been identified in this application <br />(Section 34-32.5-115(4)(e), C.R.S.). (NOTE: For 110 operations, the affected azea includes all lands delineated by the <br />permit boundary.) <br />3. No mining operation will be located on lands where such operations aze prohibited by law (Section <br />34-32.5-115(4)(f), C.R.S.). <br />4. As the applicant/operator, I do not have any mining/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.). <br />5. I understand that statements in the application aze 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. 1984. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-31.5-110,C.R.S., of the <br />Colorado Land Reclamation for the Extraction of Construction Materials. Any alteration or modification of this form <br />shall result in voiding any permit issued on the altered or modifted form and subject the operator to cease and desist <br />orders and civil penalties jor operating without a permit pursuant to section 34-32-123, C.R.S. <br />Signed and dated this ~ a~ day of ~ t / , ~L~. <br />~~~,~~~~ is If Corporation Attest (Seal) <br />T ApplicanUOperator <br />Signed: <br />Title: ~/~~,y,LPe <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of ~ ~ (~a'o.~.© ) <br />C ss. <br />County of ~ Jl^A ) <br />The foregoing instrument was acknowledged before me this~~hd" day of ~ (~. (~1 00 by <br />~n~X'Yt", J~'i'IIQV)PY'~'U as (~(rJYIPr of~PC4Ca'r~(~flf~I~CCk- <br />~~~-r~ <br />p., Notary Public <br />. ~y'p~BC/c. <br />r~ \~K~ :O <br />~Ql DEL .a My Commission expires: ~~ i ,( {')P, ~ ~~~ <br />N~QP .~ ~ <br />~ SIGNATURES MUST BE IN BLUE INK <br />