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Certification: <br />-6- <br />As an authorized representative of the applicant, I hereby certify that the operation describedhas met theminunwn requiremerds of <br />the 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 pennanentman-made structwe(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.RS.). (NOTE: For 110 operations, the affected area includes all lands delineated by the <br />permit boundary.) <br />3. No mining operationwill be located on lands where such operations are.prohibited by law (Section 34-32.5-115(4)(f/, <br />C.RS.). <br />4. As the applicant/operator, I do not have arty mining/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 3432.5-120, C.RS.). <br />5. I understand that statements in the application are being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. 1984. <br />This form has been approved by theMinedLandReclamation Board pursumrttosedion 3¢325-IIO,t^RS, oftheColorado <br />Land ReclamationAdfortheExtradionofConstrudionMaterials. Any alteration ormodiftcationofthisjormshaIIresuk <br />in voiding any permit issued on the altered or modified form and subject the operator to cease and desist orders and civil <br />penalties for operating without a permitpursuant to sectioDn 332-123, GRS y~ <br />Signed and dated this ~ day of _ ~0.6-- ~~J <br />--~4~ ' <br />Appli~cantl,0p~era~tot <br />Signed(' ~-~~- <br />I Title: ~~Z~l)`?'~/ <br />State of W~J1~a-~o 1 <br />) ss. <br />County of ~..QaS'~ ) <br />Corporate Secretary or Equivalent <br />Tovn>/City/County Clerk <br />I The foregoing instrument was acknowledged before me this ~_ day of i~a15 Ao $ <br />~ by <br />as <br />of <br />Notary Public <br />My Commission expires: L (. l •t~ <br />If Corporation Attest (Seal) <br />Signed: <br />SIGNATURES MUST BE IN BLUE INK <br />M:Amin\sfiaza\vsfom~slCanst+ucti~a110 {07nsn004) <br />