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-7- <br />e 'r tigg: <br />As an authorized representative of the applicant, l 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(1xa)(VIII). <br />2. To the best of my knowledge, all significaurt, 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 looted on lands where such operations are prohibited by law (Section 34-325-115(4xf), <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 ofthe Colorado Land Reclamation Act forthe 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 Redlamabbn Board pursuant to section 34.325-110,CRS., ofthe Colorado Land <br />ReelamatlimAdfor the Exlradlon of Construction Materials. Anyalteradon or modijlca&n of this formshall resaitin voidingmry <br />permit issued on the altered or nadijied form and subject the operator to cease and desist orders and dvilpenalties for operaling <br />without a permitpursuant to section 34=325-123, GR.S <br />?j -C a 1 6 <br />Signed and dated this --? day of O C X <br />Applicant(OperaW 'J <br />Title: Manager <br />State of-l"'& a I a d n ) <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />ss. <br />County of C a-i -t-' `-- 1 <br />? <br />The foregoing instrument was acknowledged before me this day of 2 C 4 <br />` s <br />by ?1.r. .?-- T(1 l f S as n 1 " `o .i u C, ..e_ of X .0,1- <br />j <br />Notarylic <br />My Commission expires: / l <br />SIGNATURES MUST BE IN BLUE INK <br />If Corporation Attest (Seal) <br />Signed: <br />