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-~- <br />Certificstlon: <br />As an authorized representative of the applicant, [hereby certify that the operation described has met the minimum requirements of the <br />following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 34-32.5-110(1)(a)(Vll[). <br />2. To the best of my knowledge, all significant, valuable and permanent than-made stmcture(s) in existence at the time this <br />application is filed, and located within 200 feet of the proposed affected azea have been identified in this application <br />(Section 34-32.5-I15(4)(e), C.R.S.). (NOTE: For 1 l0 operations, the affected area includes all lands delineated by the permit <br />botmdaryJ <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-115(4)(f), <br />C.R.S.). <br />4. As the applicanNoperator,l donot haveany rnining/exptoration operations in the State of Colorado currently in violation of <br />the provisions of the Colorado land Reclamation Act for the Extraction of Construction Materials (Section 34-32.5-120, C12.S J. <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 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />Thisjorm has been approved by the Mlned Land Reclamation Board pursuant to section 34-32.5-IIO,C.RS., ofthe Colorado Land <br />Reclamation Act jor the Extraction of Construction Materials. Any alteration or modifrcation of this form shall result in voiding <br />any permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties jor <br />opernting without a permit pursuant to section 34-32,5-123, C,R.S. <br />Signed and dated this 12th <br />day of September 2007 <br />Cheyenne County <br />ApplicanUOperator <br />Signed: ~elXik11A1?~1J1m.Q.f~ <br />Title: <br />County Administrator <br />[f Corporation Attest (Seal) <br />Signe~/7C,LCaa~(-1~'~Q-(~YtQ~~~ lA <br />Teva6ity/County Clerk <br />Srateof Colorado ) <br />) S5. <br />Countyof_~Cheyenne _) <br />The foregoinginstmr~ntwasacknowledgedbeforemethis 12th_dayof September___ 2007 <br />by Marcy L; Brossman _ as County Administrator of cheyenne_county <br />~,.,, 1, <br />~``3-.__.~~_---~--~- <br />%. Nota Public V9o~9 [e K~ qst~ Co 80?~0 <br />~ '• - :~_ <br />.~ ~~ .. rr, ; ! =_ My Commission expires: ~~ `a.O <br />~. <br />5- ~ ~ ~ <br />"', -= -~: r'- SIGNA'1'17RF,S MUST QE IN BLIIF. INK <br />.~ <br />`~~ <br />..+•o <br />