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M <br />Certification: <br />As an authorized representative of the applicant, 1 hereby certify that the operation described has met the minimum <br />requirements of the following tenns 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)(c), 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, 1 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 approved by the Mined Land Reclamation Board pursuant to section 34- 31.5- 111,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this fora: shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease air# li4sisi ders and civil penalties for operating <br />without a permit pursuant to section 34 -31.3 -113, C. R.S. `�\ SOUR ; <br />14 t '• CFA/ i <br />Signed and dated this �l day of «��- � 0Q 3V .�(?A,q�; • - <br />Connell Resources, Inc. 1rC`orpo tiort'Atte.U(Seal) <br />Applicant/Operator or Company Name �► O ts�p •;' <br />,2 i 0 <br />� ....•••gip <br />OLF ` �i��1t.L <br />Signe .41 1 11��` � �== <br />Corporate Secretary or Equivalent <br />Title: President <br />State of C- C> r 01- ) <br />ss. <br />County of L--- � ) <br />Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this 1 I day of (D , <br />zo I ,by Q ,c.V--c..,L as 31 r- S L. of <br />AMBER C JORGENSEN <br />NOTARY PUBLIC Notary Public <br />STATE OF COLORADO <br />NOTARY ID 20134034207 3 t <br />My Commission Expires May 30, 2017 My Commission expires: 5 1 <br />SIGNATURES MUST BE IN BLUE INK <br />You must post sufficient Notices at the location of the proposed thine site to clearly identify the site as the location of a <br />