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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 34-32.5-110(l)(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(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(4)(f), <br />C.R.S.). <br />4. As the applicantloperator, 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 Reclamadon Board pursuant to section 3¢32.5-I10,CRS., of the Colorado Land <br />Reclamation ActfortheF-wracdon of Construction Material& Any alteration ormodiftcation ofthis form 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 3¢32.5-123, CRS. <br />Signed and dated this ?/ ray of <br />If Corporation Attest (Seal) <br />Signed: , <br />Corp to Seore r Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this day of ,by 2, • J G01?' LLtl N4 as 0M ,1/,V - of cZnJil1a l:d &-ri1' ->, U C, . <br />K. <br />?,Q` ?pTAR?, acs <br />k <br />9 BL?G <br />'lip ?? .....?''' Q?P? <br />rr?rii...OF C0?-? <br />o Mo rc <br />nission expires: <br />SIGNATURES MIDST BE IN BLUE INK <br />MY COMMISSION EXPIRES <br />JULY 93, 20 <br />ss. <br />County of I I `twiw Q )