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-~- <br />Certificafion: <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements ofthe <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 [he best of my knowledge, all significant, valuable and permanent man-made structure(s) inexistence at [he 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, [he 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.S.). <br />4. As the applicant/opetator, I do not have any mining/exploration operations in the State of Colorado currently in violation of <br />the provisions ofthe Colorado Land Reclamation Act for the Extraction ofConstruction Materials (Section 34-32.5-12Q C.R.S.). <br />5. I understand that statements in the application aze being made under penalty ofpequry 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. S-IIO,C.R.S., ojthe Colorado Land <br />Reclamation Actjarthe Extraction ajConstruction Materials. Any alteralton or madifrcatton ojthisjorm shall resultin voiding any <br />permit issued on the altered or modified jorm and subject the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this / / ~ day of L~GX~/Ll~ o?Od <br />d1?A2rc Kok'ES _mM Pam <br />ApplicanUOperator <br />Signed: ~~/n <br />Title: ~{(~~ - ~/~ 1 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of ~~ ) <br />ss. <br />County of ~ ) <br />The foregoing instrument was acknowledged before me this .3 ~ day of ~YL4i'/ ~ a O D <br />_, by YY~aO /°~d-~1.2C~ as ~ ~~..t.~pq _ ,~l _ p of <br />MMM.6W~ <br /> <br /> <br />. <br />'`> ~.~ <br />w <br />~:. <br />`.~.q /y <br />, . c7 <br /> <br /> <br /> <br />~' r ^Y <br />Notary Public <br />My Commission expires: ~ (o ~ a. 7 - 0 7 <br />=.; ~1~~'•.._E'~ ; ,.••'}'.,;~ SIGNATURES MUST BE IN BLUE INK <br />ry <br />M:1min\shafeWsfgn/)S1Gon5tiuction110 (Approved OS/I I/2005) <br />