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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has rnet the minimum <br />requirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, vahrable and permanent man -made structure(s) in existence at the time <br />this application is filed, and located within 200 feet ofthe 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 twill 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 extract ioru/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 />T his form has been approved 4j, the Alined Land Reclamation Board pursuant to section 34- 31.5- 112,C.R.S, of the Colorado Land <br />Reclamation Act for the Extraction of'C'onstruction Aaterials. Atty alteration or modification of this form shall result in voiding any <br />permit issued on the altered or modified fornt and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pttrsttant to section 34- 32.5 -113, C. R. S. <br />Signed and dated this 1Cs3t day of .0 " "� s� zrL 1✓ /.:� <br />6e( is l Cez 1 � fLit` x If Corporation Attest (Seal) <br />Applicant /Operator or ompany Names ` <br />r_ t <br />Signed: <br />Title: Phillips County Commissioner <br />State of t C iG�rit n ) <br />` ) ss. <br />Count) of <br />Signed: ( <br />Corporate Secretary or Equivalent <br />Town /City /County Clerk <br />The foregoing instnrnent wasacknQw]edged before me this le�olt da} of <br />i, <br />by IX as of {, <br />C'lltz `� - -- <br />RANDALL D. SCHAFER / <br />NOTARY PUBLICa'� <br />STATE OF COLORADO Notary Public <br />NOTARY ID 19954016062 <br />MY COMMISSION EXPIRES 12/06/2016 My Commission expirclS�_K / <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 />