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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 />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 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 34-32.5-1 I5(4)(e), C.R.S.). (NOTE: For 110 operations, 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 aze prohibited by law (Section 34-32.5-I1S(4)(f), <br />C.R.SJ. <br />4. As the applicant/opera[or, I donor have any mining/exploration operations in [he State of Colorado currently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction of Constmction Materials (Section 34-32.5-120, C.R.S J. <br />S. I understand that statements in the application aze 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 />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 for the Extraction of Construction Materials. Any alteration or modification ajthis form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties jor operating <br />wNhout a permrt pursuant to syectron 34-32.5-IZ3, C.R.S. / <br />Signed and dated [his J ~ day of S~¢O t c.m ~ t ~ ~ /~) 7 <br />A~ppilicantlOperator <br />Signed: ~// <br />If Corporation Attest (Seal) <br />Signed: <br />Title: ~~,O,~i~~/cr~_S // IIGtN~r7~/' <br />~O//IY~ l~ TGLGT~ <br />State of ~~tfi~ 1 <br />ss. <br />County of~e~ ) <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoin-g7instrument was acknowledged before me this _ ~7"j day of \ 1 i~-n'f / f~.jy l~l7D~ , <br />_, by 1'~ y r~~~F~/YY41t~ as ~nwrR~-idNS mfF/1'~Cj °~ of <br />~rR.~~tO1Y C~~LpCJ. <br />2o,~~tY PVe~• ~ , <br />•(1 N~ Public <br />• ODg <br />(`,~~ L. ~ My Commission expires: <br />~~$ ~:Q <br />~~~•.._ _ _ __..•S•W IGNATURES MUST BE IN BLUE INK <br />OS/I1l2005) <br />