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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 of the <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,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. <br />Signed and dated this / day of (4 b (1 a_ DI J <br />£ r r' 1 c� C r`4 B e y' <br />C �' 7 / C' 1- \ G r 64, If Corporation Attest (Seal) <br />Applicant/Operator <br />Signed: <br />Title: 614 LA) <br />State of O. e, ce veal-) ) <br />) ss. <br />County of R Qv�Q,n ) <br />The foregoing instrument was acknowledged before me this <br />- 7 - <br />day of IV.A&ltt_Ip.,¢ -r - AQ , <br />, by r {, L eincor-1-1 etr as EL AD e-V of 0.__INA.1r i e. v ScL4Gt i- GYuLiU -L. <br />1: PAMELA J. BRUNGARDT <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />My Commission Expires: 1 D -17- 1 S <br />Signed: <br />Corporate Secretary or Equivalent <br />Town /City /County Clerk <br />SIGNATURES MUST BE IN BLUE INK <br />My Commission expir- : 10-1 '1-1S- <br />