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06125/2009 15:42 9702475104 DMG DURANGO OFFICE PAGE 11/13 <br />(-,C)'t1f f--Wh ; <br />-R <br />As an. authorized representative of the. applicant, i hereby cer, tifythat tl.1e r4icTatitm described has met thi- ni..inianum m-gtiireme:lt- <br />of the, Following tevrr?.ti and conditions: <br />1. To the hest of my knowledge, all significant, valuable and pern anent man-made structure(s) in existcnsc at the ti..me <br />this application is filed, and located within 200 feet: of the pmposcd affboted area have been identified in this application. <br />(Section. 34-32.5-115(4)(e), C.R.S.). <br />2. No milling operation will be located cal. lands whcrc such, operations are prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S,; <br />3, As the spplicant/operator, I do not have any c?ctXactio l?exploration, operations in the State ofCol.orado cvrrf tzfy in <br />violaficm of the provisions of the Colorado Land Reclamation Act for the Extraction of Constnlction. Materials <br />(Sectiop 34-32,5-120, CRS.) as determined through, a Board finding, <br />4. I understand that statements in the application are being made under penalty of perjury and that false statentents <br />rrtad(; herein are punishable as a Class 1 misdemeanor pursuant to Section 1.8-8-503, C.R.S. <br />This fetm has been approvedby fhe Afbred Laird Reclamation Board pursuant to .Section 34-31.5.112, C.It S., of the Cafarad* .Land <br />,Recfamaden Acifar the Extracdan ofConstmclion Alaterialx 4rey afterodan or modification of this fo rm shall resfrft 1h voidhig any <br />permit &suea? an the altemi f or nfodifled form and subject the operator to cease and desist ordesi and cfvlf peonaldes,afor operating <br />tvitkont a,perarft prrrswant to sertton 34-3Z5-123, C.R.S. <br />Sig>;ed and dated this 'Z:5 day of-- 11 11-.-..----' <br />?-_- <br />' RL J O TS ff Corporation. Attest (Sc2.1) <br />ApplicanWperator or Company Name <br />Signed _ <br />Title. ...._....-- <br />Signed: <br />Corporate Secretatr or .Equivalent <br />Town/City/County Clerk. <br />State of ...01 blf p ?._...._....._....3 <br />'lie tcs+° :r34:!. Oiamun-p-n+ t,•d <br />" r+i' }? 1 <br />_ S. day y <br />by <br />J Az <br />097" MCLAUG WN Notary Pvblic <br />Notary Pubrit <br />State of Gclomda f o <br />My Comniissiun expires-, t <br />. C?!..... f <br />S1t;: r-Al€}R.ES ;V11L.ST HF VN 131,.1IE INK