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Wel1lqc <br />y ides? <br />l <br />-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 />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(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, 1 -do not-have any mining/exploradon operations in the State of Colorado cur; ently inns 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, C-Rg, of the Colorado Land <br />Reclanadon Act for the Extraction of Construction Materials. Any alteration or modification ofthisform shallresult 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, GIL <br />Signed and dated this day o <br />i d 1-5d!? &a ohi <br />Applicant/Operator <br />Signed: " r'V <br />Title: E0 k- --0- YYl Q ki State of <br />) ss. <br />County of <br />41-- <br />The <br />, by <br />was <br />' " """•...jf Corporation Attest (Seal) <br />?. •... -, COG <br />Si" <br />SEAL 141, <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />day of <br />Q'? p A y. .? <br />_ otary Public <br />N9T • AU g?\?; OAT ,?o^ My Commission expires: <br />?_ <br />OF GO <br />G ST BE IN BLUE INK