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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 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 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,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of thisform 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- 32.5 -123, C.R.S. <br />Signed and dated this 1 4 4 K day of {0 f ab <br />W e,Ld Cb 'N�Ixk'c W If Corporation Attest (Seal) <br />Applicant/Operat9r or Company Name <br />Signed: <br />Title: 1JtfQ.Jy<— J _�,A Lc_ lx°x�c-L1S <br />State of (Otofjy ) <br />ss. <br />County of W 0 ) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this N day of A,�, r <br />/j <br />ao L ,by �i�ecm as 1 -'j /hCJ) a (� of (AJ�J� Cou,�, I iv�lTc <br />:NOTAR ARON BENSON' PUBLIC <br />ATE OF COLORADO Notary Public <br />Y ID 20084020155 <br />SSION EXPIRES MAY 24, 2018 <br />My Commission expires: 78 <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 />