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Certification: <br />4 r �,' �� �, �� � ,.� c l t p l e j <br />Applicant/Operator <br />Signed: <br />Title: )c- c 1 .Q. <br />State of Cr)/ 0 YG A o ) <br />( ss. <br />County of TG'`Cb� spy% ) <br />The foregoing instrument was acknowledged before me this .26 <br />DEBRA L. <br />NOTARY PUBLIC <br />E <br />STATE OF COLORADO l <br />4. -►• .9.ad ,,- ,,,� SIG TURFS MUST BE IN BLUE INK <br />My Commission Ex 0 6/2 p� 3/201 `e <br />pi <br />RECEIVED <br />-7- AUG 0 4Z011 <br />Division of Reclamation, <br />Mining &Safety <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum require n ants of the <br />following terms and conditions: <br />1. All necessary approvals from local government have been applied for (Section 34- 32.5- 11.0(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,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. 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. 1 <br />Signed and dated this ( 2 67 .6 day of T t.k 1 n l l <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town /City /County Clerk <br />day of <br />L tAly aoi <br />, by Ha ' -y �(, �' k S` as t 5 /C ;7Li" o f /-16? r d `t?; / / i �,, <br />! t�NS® <br />A-0_ <br />My Commission expires: <br />ro / ? 3� ja. <br />