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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(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 applicantloperator, 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 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- 32.5 -112,0 RS., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or mbdif cation of thisform shaft 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 34 -32.5 -123, CR.S. <br />Signed and dated this Al a day of &nw2da <br />Applican /Operator or C mpany Name <br />Signed: <br />J Gs�c <br />Title: Washington County Road and Bridge DO Foreman <br />State of 6060 {cLold ) <br />) ss. <br />County of <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />If The foregoing instrument was acknowledged before me this ��% day of3 <br />90 —///, by C�nriS �itrL , �l�a^5 . C.D - as rye vrtG A of <br />Notary Public <br />RANDALL D. SCHAFER <br />NOTARY PUBLIC My Commission expires: !2 D <br />STATE OF COLORADO <br />NOTARY ID 19954016062 <br />MY COMMISS- 11NBl�iRl9b'410 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 />