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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man -made structure(s) in existence at the time <br />this 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.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34- 32.5 - 115(4)0, C.R.S.; <br />3. As the applicant/operator, I do not have any extractionlexploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34- 32.5 -120, C.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34- 32.5- 112,C.R.S., ofC # <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shatcl; � 3 <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil ker.W <br />without a permit pursuant to section 34 -32.5 -123, C.R.S. <br />Signed and dated this _ day of ^ -9-0. a 4 ° r' <br />•enoa <br />L.G. Everist, Incorporated <br />Applicant/Operator or Company Name <br />Signe Q -- <br />Title: Vice President <br />State of ) <br />ss. <br />Count of ) <br />If Corporation Attest (Seal) <br />Mol� <br />NOTARY <br />PUBLIC <br />'r <br />.4' <br />Signed:. taS <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />y <br />-Nv <br />The foregoing instrument was acknowledged before me this day of , <br />p�ok- by Dennis L. Fields as vice President of L.G. Everist, Incorporated <br />Notary Public <br />My Commission expires: /9 L.20 % <br />SIGNATURES MUST BE IN BLUE INK <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a <br />