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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 Is 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 an }, 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. 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 />7his form has been approved kr the Alined Land Reclamation Board pursuant to section 34- 32.5- 112,CR.S., of the Colorado Land <br />Reclamation Act for t/re F..vtrcrction of Construction Materials. Amp alteration or rnoclifrcatian cif this form shall result in voiding ctnt' <br />perrrrit issued on the altered or modifred form and subject the operator to cease and desist orders and civil penalties for operating; <br />irithoul a perrrril pursuant to section 34- 32.5 -113, C.R. S. <br />Signed and dated this %Lt day of <br />*'4' C !`t! 34 A C� .� `' L >'jj —'( =; � If Corporation Attest (Seal) <br />Applicant /Operator or ompany Name' <br />Signed: <br />,I,itle: Phillips County Commissioner <br />Signed: J tyc' <br />Corporate S cretary or Equivalent <br />Town /City /County Clerk <br />State of 6117 lei, '-f Z, ) <br />) ss. <br />Comity of <br />The foregoing instrument was.ackn Qwl edged before me this JAi day ofi'L1 <br />1. <br />by ' ft° /1 IX as of eh L&16 0 c- <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 expir4- / <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 />