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<br />_7- <br />Cerdfieation: <br />As an authorized representative of the applicant, l hereby certify that the operation described has met the minimum requirements of die <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 ratan-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)(c), 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/explo; ation operations 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.R.S.). <br />5. 1 understand that statements in the application are being made under penalty ofperjury and that false statements made herein <br />are punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.R.S. 1484. <br />• <br />This form has been approved by the Mined Laud Reclamation Board pursuant to section 34-32.5-110,C.R.S., of the Colorado Land <br />Reclamation Act far 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 34-32.5-123, C.R.S. <br />Signed and dated this (0774 day of___DC?Dt <br />QQD <br />--P)47 ......--..•--W'y n- U Yh `C e_ <br />Applicaut/Operator <br />Signed: <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: _--OtkjjVg, <br />State o1' <br />ss. <br />e {rrY' gmng i'n.'rr utylz rat wa aukrtr "1 edged be16m, at t4i5 /j 07W <br />I'h <br />5.. <br />by <br />Town/City/County Clerk <br /> <br />a ..tit=..... ?f ..r.u Pik r,?r ?>J <br />- - -- - ------- - - <br />N'ota i'ubhc / <br />My Commission expires:._-,..._?0??_! ---- ........._.__.._ <br />• <br />i111yCommission ExpiresO6/05/2Fi:I(.N.A't'1iRFS MUST RE IN BLUE INK