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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 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(4xe), 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. 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 />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5112,C]ZS, of the Colorado Land <br />Reclamation Actfor the Extraction of Construction MateriaLL Any alteration or modification of thisform shaU result In voiding any <br />permit issued on the 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 3¢32.5 -123, CRS <br />Signed and dated this %4 day of <br />Title: Cc, u y -T11: c, 1 <br />State of (coic,rc Ao <br />ss. <br />County of !�)e I f 4— ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this 13 VL day of F -c- It r U ,, <br />c`1` as Cou n 1-k , <br />� E n a n ec y- <br />of <br />AJi.,TI O N .R. ,F`uvL`'C ` <br />t�!�;xrc`r'i3�i.- y otary Public - <br />STATE Jr =• C-C, OP , ^.D0 <br />NOTAI :Y 1J 112C-i34-03 1313 <br />�. C y Commission expires: ,�%� .� Z, .70 / 7 <br />a "y ia..,rniss;,... Expires �S«y "2, 2017 <br />SIGNATURES MUST BE IN BLUE INK <br />