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-7- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the <br />following tetras and conditions: <br />All necessary approvals from local government }tale been applied for (Section 34-32.5-110(I)(a)(VIII). <br />2. To the best of my knowledge, all significant, valuable and permanent man-trade structure(s) in existence a[ 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 34-32.5-1 ] 5(4)(e), C.R,S.). (NOTE: Por l l0 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)(f), <br />C.R.S.). <br />4. As the applicanUoperator, I donor have any mining/exploration operations in the State of Colorado currently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section 34-32.5-12Q C.RS.). <br />5. I understand that statements m the application are being made tinder penalty ofperjttry and that false statetrtents made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />Thts form has been approved by tke Mined Land R¢c/emotion Aaard pursuant to seMlon 34-32.5-1IO,C.RS., ofthe Colorado Land <br />Reclamation Act jor the Extraction of Constradion Materials. Any alteration or modifrcatlon ajthis form shall result in voiding <br />any permit Issued an Ike altered or mod~ed jorm and subject Ike operator !o cease and desist orders and civll penahies jor <br />operating without a permh pursuant to section 34-33,2~.5-123, C.RS. ~y <br />Signed and dated [his ~ ~ day of !~"' ~f,~ ~~~ / j~ <br />State of CDC. Q <br />ss. <br />County of ) <br />The fore oing instrument was acknowledged before me this ~ ~"h day oC I " 1 A (i n ~ , <br />by ~~L.~~ t~ as Plt,h) 1 ~,~ }~..~ ~ YP~"~Y- of <br />~L~, C i t~ t~}- ~' I -F ~ . ,~R`~_ P Vie, <br />•• ,~~:~ a ma ~ ~ D~-, <br />p,N~REq ~ Notary Public <br />MA~y . <br />~ My Conrnsission expires <br />S[GA'I' BE IN BLUE INK <br />M:~min~sharc~vsfomis~Ctmswctimrf l0 (Appmve605f11/2005) ,.;~ <br />~(.L6 ~! C ~ D /L ~S v yl VPC ~ V Corporate Secretary or Equivalent <br />Title: Town/City/County Clerk <br />