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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, a I I 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)(f), C.R.S.; <br />3. As the applicant /operator, 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 I misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />This form has been approved bj, the Alined Land Reclamation Board pursuant to section 34- 32.5- 112,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Aaterials. Attr alteration or modification of this form shall result in voiding ant <br />permit issued on lire 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.K.S. <br />Signed and dated this 16- y!1 day of <br />Applicant/ ,g {or or in Nai <br />Signe . <br />Title: County Commissioner <br />State of �e, - l ir� 64 ) <br />ss. <br />County of i"'1, /% %,C13 ) <br />If Corporation Attest (Seal) <br />Signed: t✓`��r�. t6 ��, <br />Corporate Secretary or Equivalent`�+�-j� <br />Town /City /County Clerk <br />The foregoing instrument was acknowledged before me this %C `` da }' of Z,c ? ' f� _ f� / <br />o ., by ri �u �� � 5� '� "%) as %i:t /j? �t it � r of _ Ph"M /� � C �1 e� •'17� <br />RANDALL D. SCHAFER <br />NOTARY PUBLIC <br />STATE OF COLORADO Notary Public <br />NOTARY ID 19954016062 <br />MY COMMISSION EXPIRES 12/06/2016 My Commission expires: 12 <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 />