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i <br />RECEIVED <br />MAR 10 2011 <br />Certification: GRAND JUNCTION FIELD OFFICE <br />DMSIION OF <br />As an authorized representative of the applicant, I hereby certify that the operation described has met thelrNi immum 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)(VIIn. <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 34-32.5-110, C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding airy <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, C.R.S. <br />Signed and dated this -7 7-H day of 14 C 9' X' GW ZQ / l <br />If Corporation Attest (Seal) <br />Applicant/Operator <br />Signed: D!? 1? A :i_ <br />Title: L". -\--- <br />Signed: t-- <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of Nt"", b ) <br />L ) ss. <br />County of ?; DZ D + l ) <br />The foregoing instrument was acknowledged before me this --1 ] ` day of ' -Ma KC I , <br />, by ' An2LbZZ- as p e.s: of ?* ee zc F'sas' .,Rem c ,C. <br />otary Public <br />My Commission expires: ??o 13 <br />SIGNATURES MUST BE IN BLUE INK <br />A u Dmmi; siml Fxohs 0111312013