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7 <br />Certirir.ation: <br />As an authorized representative of the applicant. I hereby certify that the operation described has met the minimum requirements of the <br />followirig terms and conditions: <br />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 tiled, 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.). (NOTE: For 110 operations, the affected area includes all lands delineated by the permit <br />boundary.) <br />3. No minim operation will be located on lands where such operations are prohibiter) by law (Section 34-32.5-115(4)(f), <br />C.R.S.). y <br />4. As the applicant/operator, I do not have any tnininglexploration 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, C'.R.S.), <br />5. 1 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 approver) try the ,Mined Land Re<°Ioniation Board purstutrrt to section 34-32.5-110,C,R.S., of the Colorado Land <br />fleclantation ,act for the Extraction of Construction Haterials. Any alteration er 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 34-32.5-123, C.R.S. <br />Signed and dated this ..------_----•--.........__. day of.__ <br />CLG F6flffig, LLC <br />Applicant/Operator <br />Signed: <br />C E..__ ....._..GEI?AiTEI?- _ <br />Title: MANAGER <br />---._.-...._._._.....__._ <br />If Corporation Attest. (Seal) <br />NO CORPORATE SEAL <br />Signed:..... <br />Corporate Secretary or Equivalent <br />State of COLORADO <br />............. ........_._.._...._..) <br />) tiS. <br />t:.ttrttw s " ,WASHI,NGTO...N_.. <br />TowniCiry,"County Clerk <br />l r a< ac I ,a.. th t a ._,t b2 r.. 4 <br />Ches_k_r _W_,....Gb.auer _ ....._ } .....Manag.e.r. ..-.... ..._ ,.___.L,C. - <br />e. C <br />Notary' Public <br />DMNE R SCMENK D is <br />Notary Public NIy Corrunission expires:......._..._..__ "_..._...-'-----_....._ .............. <br />State of Colorado <br />,AT Z 7 Nf11s t 131, ( III l.`•t° INK