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-7- <br />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 />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 S- 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 <br />7rL WL_� t) If Corporation Attest (Seal) d. ' °. <br />"• °rs \ <br />Applican Operator ,, - "•-• °••` •s <br />\ <br />; <br />7. fli., llfS�t4,\�1`l` <br />Signed: Signed: <br />Corporate Secretary or Equivalent <br />Title: i L Town/City/County Clerk <br />State of C/o ) <br />s <br />County of !!i' y <br />The fore oing instrument was acknowledged before me this day of 0 r c- <br />by( NCI 5 �� r1�G U r ��� as t° S i G� c' �1� of 4 <br />L JO <br />N <br />..TA ........ s ota 1'ubh <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />q�FOF COLOP <br />MY COMMISSION EXPIRES <br />