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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 raining/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 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 M1ned Land Rec/amation Boardpursuant to section 34-32.5-110,CRS., ofthe 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, CRS. <br />Signed and dated this day of. I) r 1'1 <br />plicant/Operator <br />Signed: _ <br />Title: C` ?n Y <br />State of <br />.. ) ss. <br />County of <br />Corporate Secretary or Equivalent <br />Towtr/City/County Clerk <br />The foregoing instrument was acknowledged. before me this day of_ rl <br />b ll ?/ ? ?? t as of l` TI `i ? <br />yL__._.1'...__._........._.._-___------._..._...._._ _1 _.___._..._. <br />MERRI BRITT <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />11, <br />Notary Public <br />My Commission expires: <br />If Corporation Attest (Seal) <br />Signed: <br />My a iff ioWn rnw#!a I I /Vi 12011 <br />SIGNATURES MUST RE IN BLUE INK