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-~- <br />Certification: <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 focal 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 this <br />application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-115(4xe), C.R.S.}. (NOTE: Fort 10 operations, the affected area inchtdes all lands delineated by the permit <br />boundary.) <br />3. No mining operation will be located on Iands where such operations are prohibited by law (Section 34-32.5-115(4xf), <br />C.R.S.). <br />4. As the applicantloperator, I donor have any mining/expioration opemtions in the State of Colorado cutrenilY in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction ofConstruction Materials (Section 34-32.5-120, C.RSJ. <br />5. I understand that statements in the application are being made under penalty ofperjury and that false statements made herein <br />are punishable as a Class 1 misderrxanor pursuant to Section 18-8-503, C.RS. 1984. <br />This form bas been approved by the Mined Lord Reclamation Board pursuant to section 34-32.5-110,C.RS, oftbe Colorado Land <br />Reclamation Act for the Extraction of Consduction Materials. Any alteration or modijlcotion ojtbis form shall resuU in voiding <br />any permit issued oa the altered or modjJled form and subject the operator to cease and desist orders and efvU penakies for <br />operating without a permit pursuant to section 30-32.5-723, C.RS. <br />Signed and dated this r~ 7t'/ day of ~Cl /1l ~ , <br />^/~~S ~iaee~;.~s <br />ApplicanU tarot <br />Signed: `/ ~ - / <br />Title: ~o~b'r/!/c'~y <br />State of ~c~, Col .Q. /~,(~ 1 <br />ss. <br />County of _._ ~ <br />The foregoing instrument was acknowled <br />d1 by ~ .Q-r s ~ /~1 ~-l~ <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/CitylCounty Clerk <br />before me this ~ day of <br />C w-.~? as .t,C /~ of <br />C9: .Z <br />'aC?:~O.~ A R Y . <br />~,..iG <br />•• pUBL~ <br />Nora P 'c <br />My Conmrission expires: ~ 0 <br />S[CN~i"PIrIJ{)>,f'in~l'175T BE IN BLUE INK <br />M:Min\Shara\vsfomrs\Conswction110 (Approved OS/i 172005) <br />