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-7- <br />Certifteatton: <br />As an authorized representative of the applicant, 1 hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made stricture(s) inexistence at the time <br />this 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)(c), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f}, C R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Constriction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Board finding. <br />4. 1 understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class I misdemeanor pursuant to Section 18.8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamadon Board pursuant to section 34-32.5-112,GRS., of the Colorado Land <br />Reclamation Act for the Extracdon of Construction Materials. Any akeradan or modiJkation of thirform shall result in voiding any <br />permit Issued on the altered or modified form and subject the operator to Least and desist orders and Civil penalties for operating <br />without a permit pursuant to section 34-32-123, C.&I <br />Signed and dated this 20 day of ©c l "4- <br />Clear Creek Dist ' Water Providers, LLC 1 <br />Appjcant/6perator or , tpa iy NyW <br />Signed: --_-- <br />C <br />Title.Town/Ciry/County Clerk <br />State of6y(_y1 } <br />ss. <br />Countyof -40&hl- 1 <br />The foregoing instrument was acknowledged before me this day of, _ tr _ <br />by fx t'f GL/?2 tit is oft kar /t?,r c k- ?istr? d? 1 ?? / !1 h 7 <br />116d, <br />SUE Mq,9 ?A'F 4 ?_ 4!. ' `?id!c?I <br />. If <br />GQ?.-'nTA R ; C?? Notary Public <br />My Commission expires- Jc? <br />SIGNATURES MUST BE IN BLUE INK <br />0007