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-7- <br />Certifica ion: <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(I)(a)(VIIi). <br />2. To the best of my knowledge, ali significant, valuable and permanent than-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.R.S.). (NOTE: For 110 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 applicant/operator,l donothave any tnining/exploratian operations in the State of Colorado currently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction ofConstruction Materials (Section 34-32.5-120, CRS.). <br />5, l understand that statements in the application are being made under penalty ofpetjury 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 Lond Reclamation Board pursuant to section 34-32.5-114,C.1~S., of the Colorado Land <br />Reclamation Act for the F_rtraction of Construction Materials. Any alteration or moth, jFcation of ttris form shall result in voiding <br />any permit issued on the altered or modified form and sub%ect 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 />~ ~av ~ <br />Signed and dated this ~ day of Z ~ <br />If Corporation Attest (Seal) <br />Signed: ~~ <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of ~e, Q ~`Q~) <br />2 ,, ) ss. <br />County of ._.__ `~(~ ~ ..~..__ ~_._ __) <br />7-L- <br />'1'lte foregoing instrument was acknowledged before the this ~._`~..___~ day of _,_.~~.~..~ ______ ._....~.. ~~ ~~ , <br />by _..._..~'~.\G~~~ ~~S __._._,._.~, as __~~nY__.~.~ - --_ o~ _~`f~~~~a~.-~"_"."..;:J ~' ~ L-~ <br />ti1i~ <br />I`atary Public ~ <br />My Commission expires: ~ ~~ <br />5 ,. <br />~~... <br />SIGNA"TirRES Mt;S'I' C3F. LY I3Li;E Ii'~FK <br />~~ <br />~o :c <br />~ ;.ms <br />\~ <br />~~~~ <br />~11p~ <br />~O ~ <br />~•. ~ <br />+p-~,~ <br />w'l!'~ qqy <br />J <br />.• '~ ~~~ <br />Title: ~__ (~.(~~~ <br />