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-6- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of <br />the following terms and conditions: <br />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 at the time this <br />application is Sled, 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.SJ. (NOTE: For 110 operations, the affected area includes all lands delineated by the <br />permit boundary.) <br />3. No mining operation will be located on lands where such operations aze prohibited bylaw (Section 34-32.5-115(4)(f), <br />C.R.S.). <br />4. As the applicandoperator, I do not have arty mining/prospecting 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.SJ. <br />5. I understand that statements in the application aze being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />Signed and dated this _ ~ day of 'd/?!?. 1 o°1D~ <br />Stanley Rasmussen If Corporation Attest (Seal) <br />Applicant/Operator <br />Signed:~~~,...4c~ ~, ,,,~c~._-- Signed: <br />< Corporate Secretary or Equivalent <br />Title: Supervisor Town/City/County Clerk <br />State of Colorado <br />ss. <br />County of Rio Blanco ) <br />w <br />The foregoing instrument was acknowledged before me this ~~ day of , ' ~©~, by <br />Stanlev Rasmussen as Su isor, ~~'~ of Rio Blanco County <br />~; ~ '~ ~9 Road & Bridge <br />.- '.! <br />i <br />' .. ~ a ~ otary Public <br />y Commission expires: Gt~-Q ~9 ~f7 `)l <br />!}ly'e' ... :.aOO <br />SIGNA~, S~i4E IN BLUE INK <br />M:~mm\chare\vsfomulConsWgion110 (OS/06/2003) <br />