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-~- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that [he operation described has met [he minimum requirements of the <br />following teens 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 permanen[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(4)(e), C.R.S.). (NOTE: For 110 operntions, the affected area includes all lands delineated by the permit <br />boundary.) <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.SJ. <br />4. As the applicant/operator, I do not have any mining/exploration operations in the State of Colorado currently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction of Constmction Materials (Section 34-32.5-12Q, C.R.S.). <br />5. I understand that statements in the application aze being made under penalty ofperjury and [ha[ false statements made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />This jorm has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-IIO,C.R.S., ofthe Colorado Land <br />Reclamation Act farlheExtractianofCanshuchonMaterials. Any alteration ormodrficationofthrsjormshal[resultinvoidingany <br />permit issued on the altered or modified farm and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this <br />27 <br />day of Md Y L It ~ 0~ <br />Co~owyo Coa~ CO. <br />Applicant/Operator <br />Signed: ~ ~ `~ ~fi~"N <br />Title: Gerlsr'aI Mara9P~' <br />State of Colorado ) <br />(~ ) ss. <br />County of MoFYa.t > <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />n,,T~h~e foregoing instrument was acknowledged before me this L I ~ day of I~ IQ1~C,t I <br />µtyJ, by Ke;(-~h R . H-a lev as ~"jPnera~ Mr~npal.-' of <br />Notary Publ c ,~' <br />', e <br />'. <br />My Commission expires: OZIZS I2QT~ ' ^ - ~_ ' <br />SIGNATURES MUST BE IN BLUE INK .~=~~~ 4 _ ^~'. <br />.., a ~ _ <br />~~ <br />M:\min\share\vsfortns\Construction 110 (Approved OS/I1/2005) .-,_ <br />