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700672 09/29/2010 03:20 PM B: 00988 P: 831 DOCUMENT <br />Page: 8 of 67 R $0.00 D $0.80T$0.00 <br />Pamela M. Schneider Clerk & Recorder, Logan County, Cc <br />1111 r, FP11R1%'I0'WLI4YWW Iio, 1AU1111111 <br />-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terns and conditions: <br />1. To the best of my knowledge, all signif icant, valuable and permanent man-made structure(s) inexistence at the time <br />this 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.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(0, C.R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Board finding. <br />4. 1 understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the !Wined Land Reclamation Board pursuant to section 34-32.5-112,C.R.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 any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penal reoperating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this ,dayof <br />i i <br />l t,? <br />If Corporation Att <br />es f r n? '`? t `% <br />Applicant perator or Company ame`,,. <br />Signed: <br />Title: C'.HAt R - L.Oc ANN Co . &etfe-b or- COUNTY <br />C,O fv.% rn ) 55 10 tY E 25 <br />State of C_0?O r c?Ao ) <br />ss. <br />County of LO ?-?_ <br />Town/Cit /County Cler <br />The foregoing instrument was acknowledged before me this ?a ?, day of <br />?C <br />by 1?c?Or4\ -,r r\ 4,s?? ?`??.A C'Oµ+^;Ss.oses f Lo Avg C.tS?na' - <br />Notary Public <br />PUg0 My Commission expires: <br />JL, ' <br />SI ?GA?r t? ST BE IN BLUE INK <br /> <br />Corporate Secretary or Equivalent <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a