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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 Boardpursuant to section 34- 32.5- 110,C.R.S., of the Colorado Land <br />Reclamation Actfor the Extraction of Construction Materials. Any alteration or modification of thisform 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 4h day of JtJJ1'P /3 <br />)i ne' 5 �nei de i <br />Applicant /Operator <br />Signed:` <br />Title: L 'F6 d PS T <br />State of 0 0 �o < , I i cJ <br />If Corporation Attest (Seal) <br />Signed: <br />ss. <br />County of <br />The foregoing instrument was acknowledged before me this t 4 day of <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />, by K�C' r"c n, , ,ts ,__ as (' N P " �_ t (., � , of C' 6 C, _r <br />'J G 13 <br />Notary Public <br />My Commission expires: - C I Ll <br />SIGNATURES MUST BE IN BLUE INK <br />