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-7- <br />Certitlcatlon: <br />As an authorized representative of the apphrant, I hereby certify that thehpera4on described has met the minimum <br />requiremems of the following terms and conditions: <br />1. To the best ofmy knowledge, all signi5cant, valuable and permanent man-made stmcture(s) in existence at the time <br />this application is fi led, and located within 200 fen ofthe proposed affected area have been identified is this application <br />(Section 34-32.5-115(4)(1), C.R.SJ. <br />2. No mining operation will be located on lames where such operations are prohibited by law <br />(Sechoa 34-32.5-115(4)0, C R.S.; ' <br />3. AstbeappbcanVopem[or,ldono[have any extractiodezplorationoperationsiatheStateofColoradocurrentlyin <br />violation of the provisions of the Colorado Land Reclamation Act for the Fxtmetion of Coustt¢ction Materials <br />(Section 34-32.5.120, C.R.S.) as determined through a Board finding. <br />4. I understand that statements in the applteation arc being made under penalty of perjury and that false statements <br />made hereht are punishable as a Class l misdemwnor pursuant to Sxtion 16.8-503, C.RS. <br />This jorm has been approved by the Mined Land Reclamation Board parsuaat ro aectwn.if-32.S-t II,GR.S., ojrhe Colorado Latad <br />Rectama77ori Act for the Ezrroedon ojConstracdan Materiah. Any Nreradon or modtJ4ation of thtr form shat! nsu#!n valding airy <br />perm# trsued on the alkred or nmdljled jorm and sabJet7 the operator ro [rare and desGl Orden and civil pena#fes jor operating <br />wvNara a permit parsaam to section 3143-113, CRS <br />Signed and dated this ZG day of do % G~"" . ~. <br />Clear Creek Dutric Water Providers, LLC <br />AppljcanUOpcrator or ry N <br />Signed• Signed: /~~fi <br />C <br />TiUa ~` ~[ Town/City/County Clerk <br />smtaof-~D[arDt~d ~ <br />) aa. <br />county of ~DaC NFL 1 <br />The tore otng instrument was acknowledged before me tkis ~ day of Q~~ber <br />,by ~D~Xff ~• LL/H!~!~ as /n~l~r~ _ of~rU7/jl/lL~t.~IS>`Y~2fl~J~P/fYl~~! <br />~~ Lr~ <br />Notary Public <br />My Commission expires' ~ Jl <br />SIGNATURES MUST BE IN BLUE 1NK <br />0007 <br />