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,*j <br />Certification: <br />l Co yf/e---7e--fA e5 s et_5 • <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 />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 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,CRLS, of the Colorado Land <br />Reclamation Act for the Extraction of Construction Material& Any alteration or modification of this 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 34-32.5-123, C.R.S. <br />Signed and dated this :7 (o <br />,+C , 1 it #, t (= ;'- t C Cf' <br />Aplicant/Operator <br />Signed: f - r <br />Signed: <br />Corporate S tary or Equivalent <br />Title: C Town/City/County Clerk <br />State of en it, YG c O <br />County of 3 - - CKSOX <br />• <br />, by . /' -v <br />day of - cYtk L .R <br />) ss• <br />4 DEBRA L. GREENE <br />NOTARY PUBLIC <br />STATE OF COLORADO SIG <br />My Commission Expires 06/23/2012 <br />The foregoing instrument was acknowledged before me this .2(..o • <br />`t" as ;VC 5 re/ cc Gi,t <br />- 7 - <br />k <br />TURES MUST BE IN BLUE INK <br />f <br />If Corporation Attest (Seal) <br />day of <br />Notary Public <br />My Commission expires: <br />,M ?,01/ - 033 <br />ps <br />of /: t . ~u <br />r _ <br />/,-.7 -20 <br />RECeIvED <br />1j0 0 4 2911 <br />Division of RQC(afpatilAr <br />Mining $ Safety <br />