PERMFILE108418

• Permit No: M2004023
• IBM Index Class Name: Permit File
• Doc Date: 3/26/2004
• Doc Name: 110c Appl
• From: Phillips County
• To: DMG
• Media Type: D
• Archive: No

-6-
CertiScation:
As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements
of the following terms and conditions:
All necessary approvals from local gm~emment have been applied for (Section 34-32.5-110(1)(al(viii).
2. To the best of my knowledge; all significant, valuable and permanent man-made structure(s) in existence at the time
this application is filed, and located within 200 feet of the proposed affected area have been identified in this application
(Section34-32.5-I15(4)(e), C.RS.). (NOTE: For I10 operations, the affected azea includes all lands delineated by the
permit boundary.)
3. No mining operation wilt be located on lands where such operations are prohibited by law (Section 3432,5-115 (4)(S),
C.RS J.
4. As the apphcant/operator, I do not have any mining/prospecting operations in the State of Colorado currently in
viohtti~ of the provisions. of the Cokuado Land Reclmnation Act for the Extraction of Construction Materials (Section 34-
32.5-12Q, C.RS.).
5. I understand that statements in the application are being made under penalty of perjury and that false a+Ar~+~ts made
herein are punishable as a Class 1 misdemeanas pursuant to Section 18-8-503, C.R S. 1984.
Signed and datedthis /9 ~ day of ~r rC/~rt 2 DO
Phillips County
Applicant/Operator :. -
Signed:
Title: Commissioner
state of _L'mld~'ado
If Corporation Attest (Seal) .
Signed: ~ ~ (~~-ti-: ~/
~-
Corporate Secretary or Equivalent
Town/City/County Clerk
) sg.
County of P~Z / /~ vs J
The foregoing instrument was acimowledged before me this /~ day of ~~.i'r~pii , ~, by
-~.~,ta„^?~ as ~rN.w ~ cr,-~> of .d~~~/,~~ l'~e`~i.~r~~

Notary Public
My Commissia~n expires:
SIGNATURES MUST BE IN BLUE INK
~'_ =~_
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M~mm~tham~vafo®s`Cm4mdim110 (30/152001)