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-? ; _C4 G o <br />4-4 <br />JUN 1 x,2009 <br />DiWaim of RacWmaWn, <br />Certification: WWirtc,I and safety aTv? c C <br />As an authorized representative of the applicant; t hereby certi fy that the operation described has me tfi r,`tininxum requirements <br />of the following terms and conditions: <br />1. To the best of my knowledge, all. significant, valuable and permanent man-made structure(s) inexistence at the time <br />this 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.}. <br />2. No ruining operation will he located on lands where such operations are prohibited by law <br />{Section 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicant/operator, t do not have any extraction,'exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Declamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Board finding. <br />4. 1 understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the 3fined Land Reclamation Board pursuant to section 34-32.5-112,C t1.S., of the Colorado Land <br />Reclamation ;1ct for the .C+ctracdon of Construction Haterials. Any alteration or modification of this form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-32..5-123, C R..S. <br />Signed and dated this ?i'2 ! day of __A?.Rk L? <br />J 6RAVEL rt(pyt C ,s tjV(_ if Corporation Attest <br />{Seal} <br />!! ra <br />Applicant/Operator or Company Name .+•.. ? , <br />Signed: _-- C? Signed: <br />_ Corporate :S?ecret•?ry`ir:.F:v <br />Title: <br />State of __- <br />;i J9. <br />?...-v.x«s 1 z.. <br />Ole. <br />03 <br />SETH MCIAUGHUN <br />Notary Public <br />y tote of Colofodo <br />?Ieo MO ___ A-_ <br /> <br />', y?l ?f.}111l V.It.1' <br />--------- -- --- <br />Notary Public / <br />.%,ly Commission expires: <br />SfGNAT"t RES MUST B IN 131_VE INK