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<br />.7- <br />C:ertl_ (cation: <br />As an aratnorized representative of the applicant, i hereby certify that the operation described has met the minimum requirernents of the <br />following temps and conditions: <br />All necessary approvals from local goverrunent 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 afTectcd area have been identified in this application <br />(Section 34-32.5-115(4)(c), C.R.S.). (N(YT'E: 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 Construction Materials (Section 34-32.5-120, C.R.S.). <br />5. 1 understand that statements in the application are being made underpcnalty of perjury and that false statements rnade herein <br />are punishable as a Class l misdemeanor pursuant to Section 1.8-8-503, C.R.S. 1084. <br />This four has been approved by the i ined Land Reclamatiou Board pursuant to section 34-32.5-110,C.R.S., of the Colorado Land <br />Reclamation .get for tite Extraction of C'onstrttetiott lllaterials. Airy alteration or utodification 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. a <br />Signed and dated this=)_ day of__ <br />?G?Yrb per for <br />Signe <br />Title,: <br />If Corporation Attest (Seal) <br />Signe( <br />?G <br />Corporate Secretaryor Equivalent <br />Town CityiCounty Clerk <br />State of--?\0 Q P? <br />_..._.........._._.._._- .............._.....-- <br />t <br /> <br /> <br /> <br />-eJ T(wSwe- 2crlu Mri.)nKirl Md&ic <br />--- _.............. ................... <br />Notary Public <br />Nly Commission expires: <br /> <br />SI:f 11IIRE ` XmIIS'T BF, fN bl I E 1NIF. <br />pt' co <br />