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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)inexistence 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 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 Exaction 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 I misdemeanor pursuant to Section 18-8-503,C.R.S. <br /> This form has been approved by the Mined Land Reclamation Boardpursuant to section 34-325-112,CR.S,of the Colorado Land <br /> Reclanmtion 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 dvil penalties for operating <br /> without a permit pursuant to section 34-325-123,CRS. <br /> A <br /> Signed and dated this ✓ day of ` /', <br /> r� <br /> Lr)itS A"n 40 4 la If Corporation Attest(Seal) <br /> Applicant/Opefator or Company Narde = � <br /> Si �C Signed: - <br /> Corporate Secretary or Equivalent'' <br /> Title: Washington County Town/City/County Clerk <br /> State of i,B✓6 r¢GO <br /> w�, )ss. <br /> County of U/d5✓tin r4*y <br /> The foregoing instrument was acknowledged before me this / ` day of 416ZG�-1 <br /> by 0h,-1,S ✓'uc�e rr f d h.6a. �4�,n,N as fdP,�r ra yt of lea <br /> -VW" k1.t/Pars ! <br /> RANDALL D. SCHAFER Notary Public <br /> NOTARY PUBLIC <br /> STATE OF COLORADO My Commission expires: <br /> NOTARY ID 19954016062 <br /> MY COMMISSION EXPII_W UST 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 />