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-7- <br />Certifleation: <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 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 Boardpursuant 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 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 <br />day of <br />Coal bed Creek <br />Applicant/Operator <br />Signed: <br />Title: <br />State of Wo ra. G1 D <br />Do) ) ss. <br />County of D Q) ca S 1 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this day of Arp - I sao1 coq ?, <br />by '__!U L4/ of Cori] ?QsCi c ? /.1L!s ye- ?On <br />f /2 ? <br />(7apmmi <br />A'Wiol'? Dodd <br />vi = S8eNA <br />S?...\ <br />\`N <br />Notary Public `f 60 5 S . G &U, .'r - <br />r? o 313a?/ <br />QO rat r Lt <br />My Commission expires: <br />?_$ j <br />BE IN BLUE INK