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• <br />Certit-MatlOn: <br />As an authorized representative of the applicaffi, I hereby certify that the operation descnbed has met the minimum requirements ofthe <br />following terms and wnditions: <br />~- <br />1. All necessary approvals from local government have been applied for (Section 34-32.5-110(]xa)(VIII). <br />2. To the best of my knowledge, all significant, valuable and permanent man-made sbvcture(s} inexistence a[ [he time [his <br />application is filed, and located within 200 fee[ of [he proposed affected area have been identified in this application <br />(Section 34-32.5-115(4Xe), C.RS.). (NOTE: For 110 operations, the affected area includes all lands delineated by the permit <br />bourxtary.) <br />3. No mixing operation will be located on lands where such operations are pmhibited by law (Section 34-32.5-115(4xf), <br />C.R,S.). <br />4. As the applicandopemtor, I donor have any mining/explomtion operations in the Smte of Colorado cunetttly in violation of <br />the provisions of the Colorado Land Reclamaton Act for the Extraction of Construcfion Materials (Section 34-32.5-1 ZQ, C.R S J. <br />5. I understand that statements inthe application are being made under penalty ofperjury and that false statements made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section I8-8-S03, C.R.S. 1984. <br /> <br />• <br />Thisjorm has been approved by the Mined Land Reclamation Boardpursuant tosedion 34-32.5-IIO,GRS., ojthe Co%rado Land <br />RedarnationActjartheE,YfiacJionofCanstntdionMalerials. AnyaUerationormodifrcatianojthisjarmsballresultin.nidingany <br />permit issued on the altered or modified form and subjed the operator to cease and desist orders and civil penahies jor operating <br />without a permit pursuant to section 34-32.5723, GRS. <br />Signed and dated this <br />day of <br />J ~~~~W <br />Cannon Rim Stone L.L.C. <br />Applicant/Opemtor <br />r <br />l t ~, <br />Signed: ~.~U./tA~u.r Y(a.la-/.G/J e~ti <br />v <br />Title: member/manager <br />State of Colorado <br />If Corporation Attest (Sea1) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />ss. <br />ColmrvoY Las Animas } <br />The foregoing instrument was acknowledged before me this 7 ~ day of ~~ 1- IZ 1, <br />_,bv Florence Jackson as member/manager -" of <br />Canyon R.imrStone LLC. <br />Notary Public <br />My Commission expires: j--L ~ 17 -0 1„ <br />SIGNATUBES MUST BE IN $LUE INK <br />Maminwlurc\vafarms\Conatruction110 (Appmved OS/11/2005) <br />