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VA e- ? t(c, ) <br />PX4 P N-5-e I <br />-7- <br />Certification: <br />?'VI - /t7,94 2 , o 7 <br />iO/Yi?)' / <br />& 23-/0 <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 />1. All necessary approvals from local government have been applied for (Section 34-32.5-110(l)(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), CLL.). (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 appiicant/operatur I-do not have-any-mining/exploration opertionsin the State of Colorado curl ently-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. 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 LandReclamadon Boardpursuant to section 34-32. 5-110,GRS, of the Colorado Land <br />Reclamation Actfor the Fatracdon of Construction Materials. Any alteration or modification ofthisform 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. <br />Signed and dated this day` <br />Applicant/Operator <br />Signed: 14AA-mi <br />Title: <br />PDr-Prna- h <br />State of <br />- - ) ss. <br />County of <br />The forego' g instrume t was act ledged before me <br />' by <br />If Corporation Attest (Seal) <br />`?gON.Cp. . ?'/l% <br />sus Nigned <br />f ? Corpo to Secretary or Equivalent <br />Town/City/County Clerk <br />'?'', CoLORP®? , <br />S W ?Ek? <br />a42? ';o <br />.o <br />Q <br />T? OF <br />day <br />Notary Yumic V'zt?.- <br />My Commission expires: <br />L/ <br />BLUE INK