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Certification: <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements of the <br />following terms and conditions: <br />Signed: <br />1. 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 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 ut eutly 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 ofperjury 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., ofthe Colorado Land <br />Reclamation Actfor the Extraction ofConstruction Materials Any alteration or modification of this formshall 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, C.R.S. <br />Signed and dated this 9 day of a, ,,z0/ <br />if; ..k Attu! L. Va At 5 1 7 If Corporation Attest (Seal) <br />Applicant/Operator / <br />Title: Owner- Operator <br />State of 6D 1 o ra do ) <br />) ss. <br />County of J a Ch So v1 ) <br />- 7 - <br />SIGNATURES MUST BE IN BLUE INK <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this - ` day of / ` t 1- <br />,byRt c..12ard L. wC( .2y as of <br />Notary Public <br />My Commission expires: (,4 - a c i — aO I l <br />