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-?- <br />Cer i~fication: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the <br />fotiowing terms and conditions: <br />1. All necessary approvals from local government have been applied for (Section 34-32.5-1 l0(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 34-32.5-115(4)(e), C.RS.). (NOTE: For 1 l0 operations, the affected area includes a!1 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 applicantloperator, I do not have any mining/exploration operntions 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 of this form shall result in voiding <br />any permit issued on the altered or modifred form and subject t/re 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 <br />24th <br />Western Grave3? LLC <br />2008 <br />If Corporation Attest (Seal) <br />Signed: <br />State of Colorado ) <br />ss. <br />County of Rio Blanco ) <br />Corporate Secretary or Equivalent <br />TownlCityiCounty Clerk <br />The foregoing instrument was acknowledged before me this 2 4th day of January , 2 0 t7 8 , <br />_, by _ Benton n n as of <br />9~. <br />~~~~"~"~ Notary Public <br />NoT~y t I~ I :~0 I j <br />,~.~.,,~, My Commission expires: <br />.TURFS MUST BE IN BLUE INK <br />day of Januar <br />M:1min~SharewsfomislConstruction 110~,,,,~ ~2W5) <br /> <br />