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719958 05/28/2014 08:12 AM 6: 01008 P: 131 DOCUMENT <br /> Page: 8 of 83 R $ 1«0.00 0 $0.00 T $0.00 <br /> Pamela M. Bacon Clerk eeorder, Logan County, Co <br /> III 1 �1�L I G 'V�i�'1��1rI III 1 I,�9 u IN II <br /> - 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 Boardpursuant 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 34-32.5-123, C.R.S. <br /> Signed and dated this day of <br /> A(7 Ct Cl Cv, ";"- If Corporation Attest(Seal) <br /> Apple t/Operator or Co pang Name <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: 0_42Q�Ad-kq,'� Town/City/County Clerk <br /> State of CO 0✓a O ) <br /> ss. <br /> County of an ) <br /> The foregoing instrument was acknowledged before me this 5+A day of 6' I Q , <br /> 02 ,by CA) as D,xra -S wana'ee of 2n /�oaccl <br /> V Vri C <br /> aOGERs <br /> i <br /> ,tPRY <br /> Q : p <br /> Notary Public <br /> yam,• `' Q d <br /> C.) My Commission expires: <br /> PO <br /> BE IN BLUE INK <br /> �����IlIUI f 1111A��1 <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 />