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Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements ofthe <br />following terms and conditions: <br />1. All necessary approvals from local government have been applied for (Section 34- 32.5- 110(1)(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(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,GRS., ofthe Colorado Land <br />Reclamation Actfor the Extraction of Construction Materials Any alteration or modification of this formshalt 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 "1; day of \ .1 t4 ;= ?( 1 t <br />Signed: <br />Title: <br />pplicant/Operator <br />- 7 - <br />State of Co ldracir) ) <br />) ss. <br />County of`T ckSpn ) <br />The foregoing instrument was acknowledged before me this .gyp f <br />by JLlY�a �— n as p` <br />4.z6p, AM-H _ 4- raNf.A5 <br />M -A ` Ri(4- 60)57- Corporation Attest (Seal) <br />1J-it� <br />DEBRA L. GREENE <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />My Commission Expres 06/23 /201 §IGNATURES MUST BE IN BLUE INK <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />day of <br />of <br />� p Corr P4wY n► / E.- <br />Notary Public <br />My Commission expires: 6/2 3 /,Q <br />