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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 [he <br />following terms and conditions: <br />All necessary approvals from local govemment 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 filed, and located within 200 feet of the proposed affected azea have been identified in this application (Section 34-32.5- <br />115(4)(e), C.R.S J. (NOTE: For 110 operations, the affected azea includes all lands delineated by the permit boundary) <br />3. No alining operation will be located on lands where such operations aze prohibited by law (Section 34-32.5-115(4)(f), C.R$.). <br />4. As the applicant/opera[or, I do not have any mining/prospecting 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, C.R.S J. <br />5. I understand that statements in the application are being made under penalty of perjury 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 />f <br />Signed and dated this ~ ~ ~ day of t[.n ~ <br />John R. Kurtzer <br />Applicant/Operator <br />Signed' _ <br />Title: Operator <br />State of Colorado ) <br />ss. <br />County of Phillips ~ <br />h~;~ <br />The foregoing instrument was acknowledged before ~ ' <br />.g <br />John R. Kurtzer ; Oc~+me <br />T <br />i <br />~~ i~/t1 <br />q~. ~J <br />•.. <br />OF <br />e2O0 ~ <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />day of J tin e , aoo a , by <br />t pf Kurtzer Gravel Pit <br />Ily6tunmA~baExtr!>^ t+r~vly,Commission expires: )l- ~- doD a <br />SIGNATURES MUST BE IN BLUE INK <br />~ M:U1IN+SHARENSFORMS~2821CO10.APP 10/15/Ol <br />