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7- <br />Certification: <br />As an authorized representative of the applicant, I hereby cettify that ibe operation described has met the minimum requirements of the <br />following terms and conditions: <br />All necessary approvals from local govemrnent have been applied for (Section 34-32.5-110(I)(a)(VIII). <br />2. To [he 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 34-32.5-11 S(4}(e), C.R.S.). (NOTE: Por 110 operations, tkw affected area includes ail lands delineated by the permit <br />boundary.) <br />3. No miniry; operation will be located on ]ands where such operations are prohibited by law (Section 34-32.5-115(4)(f), <br />C.R.S.). <br />4. As the appticant/operator, I do not have any mining/exploration operations in the State of Colorndo ettrrently 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 ender penalty ofperjury and that false statements made herein <br />are punishable as a Class ]misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />Thtsform has been approved by th¢ Mined Land Reclamation Board pursuant to section 34-32.5-/JQC.RS., ofthe Colorado Land <br />Reclamation Act for the ExtraMion of Construction Materials Any alteration or modification of this form shaft result in voiding <br />any permit issued ox the altered or madifred form and subject the operator to cease aed desist orders and civil penalties for <br />operating without a permit pursuant to section 34-32.5-723, C.RS. <br />Signed and dated this ----~---day of ~G.ed j2. z UO <br />Mike Bennett <br />ApplicanU'Operator <br />Signed <br />Ti[Ie:QtmP,_r/Onaratnr <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of ~a~o/q~1O ) <br />,p / ) ss. <br />County of % /1 / ~/~,~5 ~) <br />'fhe foregoing i,~nrstmment was acknowledged before me this j'2 ~t <br />2op2, by ____!' i t ~~P ~p t141~~"1- as _ <br />.nett QiF <br />_ day of ~D'/Lfl~'l __ , <br />__.~1~rJ y1 8 tr ' ~ of 1~(t Q <br />c~_1~4_ ~I~j~- i v <br />Notary Public ~ ; ••' <br />., ` <br />J ~ ~ ,r~'~' ~~~ <br />My Commission expires: .'~~ ~ ~ =..',~~ ~,~ <br />SIGNAT[)RES M[15T BF, [N Bf,[Jti INK <br />M:~min\shazelvsfa'ms`GonsVUCtian 110 (Approved OS! I I12W5) <br />