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W12 <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 terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man -made structure(s) inexistence 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. 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 l 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 for the Extraction of Construction Materials. Any alteration or modification of this form shall 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- 31.3 -123, C.R.S. <br />Signed and dated this — day,of <br />Applicant/Operator or Company Name' <br />Signed: <br />Title: <br />If Corporation AtteM (Seal) <br />Signed; W1 <br />1 <br />Corporate Secretary or Equivale <br />Town /City /County Clerk <br />State of Op ( o 1-aAc 5 <br />ss. <br />County of W eA a ) <br />The foregoing instrument was acknowledged before me this 5�-� day of Q�QrJ , <br />Cy, M s VILA as Tres, 0(1_, o k —of SUPEriOr 01 Flog �Xt n `�S <br />RHIANNON WINDER <br />Notary Publlc No ry Public <br />State of Colorado <br />Notary ID 20144014340' <br />M. Commission Expires Apr 2 2018 <br />My Commission expires: r Cqu l� <br />ATURES 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 />