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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 of the <br />following terms and conditions: <br />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 applicantloperator, 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, CALS.). <br />5. I 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 Reclamadon Boardpursuant to section 34-32. 5-110,C.RS, of the Colorado Land <br />Reclamation Act for theExtracdon of Construction MateriaLL Any alteration or modification ofthisforns shall result in voiding any <br />perndt 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, CR.S,9 <br />Signed and dated this day of (J <br />Applicant/Operator <br />Signed: q'J( e .cll1i <br />Title: <br />State of <br />ss. <br />County of <br />The forego in instrume t was ac owledged before me thi day of <br />by as <br />Q`r•° QSA'?•y'??' <br />e ; <br />i ? <br />?O <br />O <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />My Commission expires: <br />IN BLUE INK <br />