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As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum 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) in existence at the time this <br />application is filed, and located within 200 feet of the proposed affected areahave been identified in this application (Section 34- <br />32.5-115(4)(e), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), CLL.; <br />3. As the applicant/operator, i do not have any extraction/exploration operations in the State of Colorado currently in violation <br />of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section 34-32.5-120, <br />C.R.S.) 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 statements made <br />herein are punishable as a Class 1 misdemeanorpursuant to Section 18-8-503, CR.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,GR.3., of the Colorado <br />Laird Reclamation Act for the Extraction of Construction Materials. Any alteration or modication of this ferns shalt result in <br />voiding any pennit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties <br />for operating without a permit pursuant to section 34-32.5123, C.R.S. <br />Signed and dated this Ze " day of !!r , 7-0o5 <br />Gsi?c EG•p5 C.ct2r°o,2?-? Ions <br />Applicant/Operator or Company Name <br />Signed: _?? <br />Title: r 0 4?07 <br />State of c c_ o.,z,gb v <br />) ss. <br />County of Lf ) <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 42 i- day of 'u c- We g Y <br />by as <br />of .11 <br />t'•. X57,.. US JAI" <br />NotaryPublic i ?:... l 7tc r 1.4 . ' l <br />My Commission expires: -1r <br />`"-tiSICNATURES MUST BE IN BLUE INK <br />office of - office of <br />W-W Laud Reclamation Denver • CraW lwutfon • Durango Derive and fnaWvP mim