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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 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 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 I 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,C.R.S., of the Colorado Land <br />Reclamation Act far 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 ��' li4sjs, orders and civil penalties for operating <br />without a permit pursuant to section 34- 32.3 -123, C.R.S. <br />VA <br />�•. Fri <br />Signed and dated this 11 day of -- 70 <br />Connell Resources, Inc. _ ' li�orpo tior;•AtteZ (Seat) Sep Applicant/Operator or Company Name v • ; <br />Sign e f 1 ►1iVd: �y� �'i�t 1411 lr <br />Corporate Secretary or Equivalent <br />Title: President <br />State of C_ C.> Cc ) <br />ss. <br />County of %Le —L-c- ) <br />Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this 1 I day of c- <br />2v1 ,by of Cu -N" A\ �sc�uc -cus �nC <br />AMBER C JORGENSEN Nota Public <br />NOTARY PUBLIC ry <br />STATE OF COLORADO <br />NOTARY ID 20134034207 <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 mine site to clearly identify the site as the location of a <br />