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-~- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify [hat the operation described has met the minimum requirements of the <br />following terms and conditions: <br />1. 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 34-32.5-115(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 are prohibited by law (Section 34-32.5-115(4)(t), <br />C.R.S.). <br />4. As [he applicanf/opemtor, I do not 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 Construction Materials (Section 34-32.5-120, C.R.S.). <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 />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32. S-IIO,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of ConstructionMateria[s. Anya(terationormodificationofthisformshallresultinvoidingany <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties far operating <br />without a permit pursuant to section 34-32.5-123, C.RS. <br />R. <br />Signed and dated this ~ ~ t day of G~,or~ I Zab ~o <br />mark ~o kes - hlmm Pcty-~-nc~al\..P <br />Applicant/Operator <br />Signed: <br />Title: (/I~WJt.cl.. - ~~ <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />~ ) <br />State of ~- <br />ss. <br />County of ...~ 1 <br />The foregoing instrument was acknowledged before me this I9tN day of lF~pp,, , <br />_, by s~R.A__ as ~ aJ1~ - XI • l~, of <br />MmM <br />^i <br />,~'tP'- ~~~•~~= ;.~~- ~ No[aryPublic <br />' ~ ~ o o - My Commission expires: D ~a Z 7 ~~ <br />-~;~L"~:'~.,.,,,.••b~'g'~~,.~ SIGNATURES MUST BE IN BLUE INK <br />re\vsfortr~SiCr6nt~iill•~i~on 110 ('; pproved 05/11/2005) <br />1 i <br />