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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 structures) inexistence 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)(1), C.R.S.; <br />3. As the applicantloperator, I do not have any extraction/exploration 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. 1 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 approver) by Use Mined Land Reclamation Board pursuant to section 34 32.5- 112,C.R.S., of the Colorado Laird <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or niodifrcatiou of tltisform shall result in voldlttg any <br />perntlt Issued on the altered or nnodifted form and subject the operator to cease and desist orders and civil penalties for operating <br />Wthont a permit pursuant to section 34- 32.5 -123, C.R.S. <br />R� <br />Signed and dated this 23 � day of OC-To3e Z Zot3 <br />Pete Lien & Sons, Inc. <br />Applicant/Operator or Company Name <br />Sign <br />Tith <br />Stat <br />Signed <br />Secretary or Equivalent <br />Town/City /County Clerk <br />� ss. <br />County of LKEI 11£ ) <br />The foregoing instrument was acknowledged before me this day of nCbAAk, X13 <br />. V Pa c� 966n by a - <br />Notary Public <br />My Commission expires: b aol <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 />