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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. 1 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 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.S-123,C.R.S. <br /> Signed and dated this 5Ltiday of <br /> If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> Signed: L ' �/-! ����f - Signed. .�.- <br /> Corporate Secretary or Equivalent <br /> Title: )Olys drly7f Town/City/County Clerk <br /> State of 00I0 0 ) <br /> )ss. <br /> County of <br /> The foregoing instrument was <br /> 'lacknowledged before me this _day of !6Gt1t's �SV�7 ,,��'", •�� <br /> by as dlSt DYf �i�2S ofof <br /> • NIII/'1G17 � <br /> i\��\\\1\till l l l ill!/IIU�r'i <br /> 4, M. M/k��9��i tary Public <br /> � NpTARy•.N - <br /> _0_0_0_ = My Commission expires: <br /> JM1V <br /> ' <br /> Q� �QQ � SIGNATURES MUST BE IN BLUE INK <br /> CcO <br /> You must post sufficINI'Votices at the location of the proposed mine site to clearly identify the site as the location of a <br />