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<br />Ivecir <br />J(/tv <br />76211,1, <br />Uur., . <br />Certification: <br />As an authorized representative of the applicant, i hereby certify that the operation described has met the min' 1 6n' requir nts of the <br />folio-,6rig terms and conditions: <br />I. All necessary approvals from local government have been applied for (Section 34-32.5-1 10(1)(a)(Vill). <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)(c), 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, l 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 & S., of the 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 7 day of h- <br />Coal b? Crick ?ortS?ru.c?ton ?vtc. <br />Applicant/Operator 1)$A C8C(??AUe.I <br />Signed: <br />If Corporation Attest (Seal) . "? <br />Signed: r!iccL•t.?s, t; <br />Corporate Secretayr OT Equivalent <br />Town/City,'C'ounty Cierk <br />Title: <br />State otl1C1 <br />) ss. <br />County of l ' <br />The foregoing instrument was acknowledged before me this .316 day of <br />by as ; k OAC1 L)e.6 of Guco k((rl ()`AU- 6+ <br />r'f?Ii ?'p? ?,rCiv P 4 <br />-- _ i ) ILL <br />?1 - <br />Notary Public <br />My Commission expires: (lL? O rL I <br />SICNA f1 RbS IvIUST BE IN BLUE INK