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-7- <br />Certification: <br />As an authorized representative of the applicant, .1 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 applicanttoperator, 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 Board pursuant to section 34-32.5-110,L:RS., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result Its 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 died this day of <br />a•G? F <br />' If Corporation Attest (Seal) <br />erator <br />Signed: _ Signed: <br />Corporate Secretary or Equivalent <br />Title: 0 w to Town/City/County Clerk <br />State of.? <br />) ss. <br />County of V'45-? <br />The ietrc lrsfingtnstrun .tut was acknowledged before the this day ofLL? _.. ._...,_.? <br />of <br />Nota?Public <br />My Commission expires <br />SIGNATURES MUST BE IN BLUE INK ? ? '