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• CerNtlcation: <br />-7- <br />As an authorized representative oftlu applicant, I hereby certify that We operation descnTxd has ~t the minimum requirements of the <br />following temp and conditions: <br />1. All necessary approvals from local government have been applied for (Section 3432.5-110(IxaxVllI). <br />2. To the best of my knowledge, all significant, vahrable and perannentman-made stmcture(s} in erzistence at the time tbis <br />application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 3432.5-115(4xe), CRS,}. (NQTE: For I to aperatiots, the affected area inchtdes alt lands delineated by the permit <br />boundary) <br />3. No mining operation will be locaud on lands where such operations are prohibited by law (Section 3432.5-t t 5(41), <br />C.R.S.}. <br />4 AstheapplicanUoperator,Idomtbavean}rminiag/explmationoperationsintluStauofColaadorwreotly~violationof <br />the provisim~ oftbe Colorado [.and ReclamationAct for the I~ttractionofConahtrctma Materials (Section 34-32.5-I20, C.RS.). <br />5. I undersmnd that statements in the application are being rrmde anderpenaltyofperjury and War false statemens made herein <br />are punishable as a Class 1 rrdsderneartor pursuant to Section 18-8-SO3, CRS. 1984. <br />1'7risfonp Arcs hero oppmved by dieMined Land Raianrafion Board paranant to sedioa 3¢325-II o,GRS, ojtheColorado Land <br />Raclmwatlon Ad for the Edrection efConsnuulon Nereids. Aay akewtion or erodiJbcodon ojthisjorar shod result in widing <br />any permit iasatd on the ahered or mod(Jied form and srrbjed the operamr to ceass and desist orders and avn penalties for <br />operating without a permit parsuaat to section 34-X3(2\5-123, CR.S _ <br />. Signed and dead this ~~. ~, day of Y Y_~~~~ . ~. <br />Richard S. Lopez/S&S Services If Corporation Attest (Seal) <br />ApplicanUt)petator <br />Sighed: °~~~ Signed: <br />Corporau Secretary or Equivalent <br />Title:- O~wlner TownlCity/County Clerk <br />Suteof l ~`Q~f ~ ~ ~ <br />((~~ } ss. <br />Countyof~9-~Vlt(V1Lt~ ~ <br />Tice fore ourg`instronrent was acknowledged before ~ this ~_ day of Y ' ~J~M dt<-~.>~ <br />`\.? ~\ , ~ ,..........~("/ ~/ice ` Y ~A Q~'~.(~4/V / a /\~ <br />~' <br />„d°;• TARy~'' <br />3e{`SO - <br />_ - Notary Public <br />-_ i C- <br />-~ NT•~... Pl!6~~~' ,~ Pr ~- My Cormnission expires: L <br />~" ' ""'~~" SIGNATURES MUST BE IN BLUE INK ,- <br />M:~nin~ShmeivsformslConswctian 110 (Appmved 05/1 llt1105) <br />