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-7- <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 I 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.RS., of the Colorado Land <br />Reclamation Actfor the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding any <br />permit issued on the altered or mod wed 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, CRS - T <br />Signed and dated this -1- day of.? PcP„rv`b e.,Y- Z0 ! ,\ <br />L,nc n (r, C, t?ell:4 <br />Applicant/Operator <br />Signed: <br />Title: Land Use Administrator <br />State of 1 ?7 kj n to 1 <br />) ss. <br />County of 1 (Cd <br /> <br />Town/City/County Clerk <br /> <br />The foregoing instrument was acknowledged before me this 19 day of \?X?.Y L_' _ z® ? <br />by _&uYy:;r_A II L/ fi!cn as <br />( ( 1m/??Ji. ?of Gb? <br />LISA M CRAWFORD <br />Notary Public <br />$to* of Colorado <br />Notary Public <br />My Commission expires: <br />If Corporation Attest (Seal) <br />Signed: y , <br />Corporate Secretary or Equivalent <br />SIGNATURES MUST BE IN BLUE INK