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RECEIVED <br />-7- <br />Signed: <br />Certification: GRAND JUNCI'10iy FIELD OFFICE <br />DIVISION OF <br />As an authorized representative of the applicant, I hereby certify that the operation descWMWAVM &WRuirements 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.RS.). <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 Construction Materials (Section 34-32.5-120, C.R.S.). <br />5. I understand that statements in the application are being made under penalty ofperjury 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 />Thisform has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-110,C.RS, 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 34-32.5-123, C.R.S. <br />Signed and dated this 1.2"1 day of ?Z? 1 - <br />A•-) gOk+t Co&4ro toA & IfCarporationAttest(Seal) <br />Applicant/Operator <br />Signed: ;''>zr? '?lG> <br />Title: Owner <br />State of Colorado <br />} ss. <br />County of Delta i <br />sr <br />The foregoing instrument was acknowledged. before me this <br />by Andrew J. Botti as <br />Owner <br />SIGNATURES MUST BE IN BLUE INK <br />NOV 2 6 2007 <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />day of do IV <br />A.J. Botti Construction & Gravel <br />My Commission expires: Z f' D