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-~- <br />Certifcation: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the <br />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 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 34-32.5-1 l5(4)(e), C.R.S.). {NOTE: l~or 110 operations, the affected area includes all lands delineated by the permit <br />boundary.) <br />3. No mining operation will be located on Iands where such operations are prohibited by law (Section 34-32.5-115(4)(f), <br />C.R.S.}. <br />4. As the applicant/operator, I do not 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 34-32.5-120, C.RS.). <br />5. I understand that statements in the application are being made under penalty ofperjury 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 form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.S-IIO,C.RS., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modifrcation ojthis form shall result in voidi~:g <br />any permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for <br />operating without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this cam- ~~ day of-~ ~.p~ _, <br />Western Gravel LLLC <br />ApplicanUOperator <br />If Corporation Attest (Seal) <br /> <br />Title: T pia. ~w- <br />State of Color_ ado ) <br />ss. <br />County of Rio Blanco ) <br />Signed: <br />Corporate Secretary or Equivalent <br />Tocvn/CityiCounty Clerk <br />'fhe foregoing instrument``wa`s~a-cknowledged before me this ~-~~' day of 1(Y14~~~~>`i , <br />-~ by ~ri V~~Q~C1~ as ~~~~~~-'~ Q of <br />O~P-S ~....~~pb, of ` Pub ' <br />~.~ •.d <br />Q ~ ~ j'.~j My Commission expires: ~1~ ~S~ l~ <br />•O <br />~ '~2 S ' ~ RES MUST B.F, IN BLUI; INK <br />v1:lmin~sharelvsForms\Cnnswctton ~ ved 05114~~^ . <br />•....• 5~ <br />