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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 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 34-32.5-115(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, 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 Constriction Materials (Section 34-32.5-120, C.R.S.). <br />5. I understand that statements in the application are being made under penalty of perjury 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,'1lined Land Reclamation Board pursuant to section 34-32.S-II0,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding <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 34-332/..5-123?,,C.R.S. <br />Signe d dated this ! day of <br />aw, If Corporation Attest (Seal) <br />Applicant/Operator <br />Signed: <br />Title: _.0 OJIV e _,__ <br />State of__l(?y?C?O <br />)Ss' <br />County o -- / 0 - - <br />__... .. --.- ___._.....-__.. <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />/ ,C-A_ <br />The fcxregroing instr'ume:rzt was acknowledged before me this day of <br />by as <br /> <br />7 <br />is <br />- r <br />S:IGNAWIRES I IUST ICE IN BLUE INK <br />Signed: <br />.My Commission expires: _ _ rP _ S -. l L.__r__..__