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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(4xe),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. 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 blind Land Reciamatian Board pursuant to secdon 34-32.5-112,CR.S,of the Colorado Land <br /> Reclamation Art for the Eztracdon of Construc hon Materials Any alteration or mod#ficaden of this formshall result In voiding any <br /> permit issued on the altered or mod fjW form and subject the operator to cease and desist orders and civil penalties for operating <br /> without a permit pursuant to secdon 34-32.5-123,CRS <br /> Signed and dated this /`! us� • '�� .... <br /> r. . <br /> G�aSh/n li`��Z C�pd17T If Cor <br /> poration Attest(Seal) <br /> Applicant/Operator or Company Nami - , <br /> Signed: Signed: A aha � ; <br /> , <br /> Corporate Secretary or Equivalent <br /> Title: Washington County Town/City/County Clerk <br /> State of 6/1013 d A <br /> )ss. <br /> County of YJ ) <br /> The foregoing instrument was acknowledged before me this /% day of Y0" t r/ft <br /> by L`/�is � c�ei.G✓�s6� ��. 44K/A as Ezim OnVA of21 <br /> o .ti�'b�alt a� S erg Gv,/Cd� s' Zee✓ a'41 4,-,- -e <br /> _... -a 4 <br /> RANDALL D.SCHAFER No Public <br /> NOTARY PUBLIC �' <br /> STATE OF COLORADO <br /> NOTARY ID 19954016062 My Commission expires: 42/Z./I <br /> MY COMMISSION EXPIRES 1210612016 <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 />