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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(i)(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 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 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 Mined Land Reclamation Board pursuant to section 34-32.5-110,C:RS., ofthe Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result ire voiding <br />any permit issued on the altered or modifred 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 KS. <br />ti <br />Signed and dated this day of AA C, .I C .V, <br />/ J .(iJ A ?-R rn rat <br />lisant/Operator <br />P <br />Signed: <br />Title: <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of S / <br />County of I- y S <br />-1 ? <br />The foregoing instrument was acknowledged before the this _ day of _ [ cd : <br />by .c.?2_! as 0' A>A" A of <br />My Commission expires: <br />SIGNATURES MI3ST BE IN BLUE INK <br />fir rTi <br />A??fflr.. .