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-7- <br />Ce coon: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum require?nents ofthe <br />following terms and conditions: <br />1. All necessary approvals from local government have been applied for (Section 34-32.5-110(ixa)(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 looted 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(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 of the 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 Redamadon Boardpursuant to section 34-325-110, CRS, of the Colorado Land <br />Redamadon Adfor the Extraction ofConstrudion Materials. Any alteration or n"ftc adon ofthis formshall result in voiding any <br />permit issued on the altered or mod#W form and xWed the operator to cease and desist orders anddvil penalties for opera ft <br />without a permat pursuant to section 34-325-123, CJM <br />--? ..G?LLL_ L b <br />Signed and dated this day of <br />1e I v f i c.. I( e C_. <br />Applicant/ <br />S' <br />S <br />Title: Manager <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />) <br />State of -C 10 <br />ss. <br />County of <br />The foregoing instrument was acknowledged before me this day of <br />by e -?n { f -C S as o A a F4 -c <br />SIGNATURES MUST BE IN BLUE INK <br />jec 1 <br /> <br />My Commission expires: /