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-7- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements ofthe <br />following terms and conditions: <br />1. All necessary approvals from local government have been applied for (Section 34-32.5-110(lxa)(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(4xe), 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, 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 I 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. R. S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modificadon 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? h ' _ day of <br />3g1) <br />Willits Company, c. If Corporation Attest:( <br />C P erg <br />Applic O rator <br />Signed Signed: 0.3 2 <br />Corporate Secretary or Equivalent <br />Title: President <br />State of <br />) ss. <br />County of?9?p,rA <br />The foregoing instrument was acknowledged before me this f? day of <br />by Robert C. Willits as President f <br /> <br />Cprllil.rY OF STA1AlY <br />t.AflA0t1E <br />Town/City/County Clerk <br />o/a <br />Inc. <br />1NuUgy ?ruui1? ! , <br />. <br />5,Z ? <br />My iCoo{mmission expires: <br />SIGNATURES MUST BE IN BLUE INK