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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 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. 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 Reclamation Board pursuant to section 34-32.54IO,C. RS., of the Colorado Land <br />Reclamation Ad 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 modyled form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-325423, CRS <br />Signed and dated this 1-7-f*- day of De.cP,.m b e/Y- ,2-01'0 <br />_ i rlca? r G v If Corporation Attest (Seal) <br />ApplicantlOper for <br />Signed: Signed: - --- - <br />\ Corporate Secretary or Equivalent <br />Title: Land Use Administrator Town/City/County Clerk <br />State of ) <br />ss. <br />County of ) <br />The foregoing instrument was acknowledged before me this day of b6'Y') <br />, by <br />as <br />of <br />LICI 01 <br />Notary Public <br />My Commission expires: Mf7j 1-7, ao <br />USA M CRAWFORD <br />Notary Public <br />$110114 of Colorado <br />SI ATURES MUST BE IN BLUE INK