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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 34-32.5-1100)(4)(VM). <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.RS.). (NOTE: For 110 operations, the affected area includes all lands delineated by the permit <br />boundary.) <br />3. No training 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 applicantioperator, 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 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 band Reclamation Board pursuant to section 34-32.5.110,CR.&, of tha Colorado Land <br />Reclamation Aet jbr the Ri&avdan of Construetlon Materkk Any alteration or modijlcadon of thtr fbrm shall result in voiding any <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, CRS. / <br />Signed and dated this -1, ly day of 114'::d <br />Z-- tJ 6, <br />Applicant/Operator <br />Signed: 1212, n A-- <br />Title: <br />Stateof??hrd ) <br />l ) ss. <br />County of C» 4 1 1 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this L day of '--Mcj ? <br />by .?? ?n o;,-E--? as ?--v-s' of F3as- f ? -- F::-,0. <br />sec-1-679-'l <br />oPublic <br />--- -- My Commission expires: l <br />F - <br />1 F 1 ? _ <br />SIGNATURES MUST BE IN BLUE INK <br />USA <br />GULLETT <br />bi,; ' mmi.-On. Exens 0102013