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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. 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 fonn has been approved by the Mined Land Reclamation Boardpursuant to section 34-32.5-112,C.RS.,of the Colorado Land <br /> Reclamation Act for the F,xtraction of Construction Materials. Any alteration or modifuatton 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 34-325--123,C.R.S. <br /> Signed and dated this l�o day of U V4 ILt <br /> �rav� C� G �aye� P�+'1 LL e <br /> If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> t7 <br /> Signed: �=� Signed: <br /> Corporate Secretary or Equivalent <br /> Title: Oc�K e/`f� 0 Town/City/County Clerk <br /> State of . Co(0 r-0,10 ) <br /> )ss. <br /> County of <br /> The foregoing instrument was acknowledged before me this 1�o �` day of k w (� A <br /> AL0 by ��1-J` L -C(-aas Q W K.0 1` I CI`k4-1 r of K_ ( 4"1�, �•G-C. <br /> l e �A�„am'RIu�Y'�''as <br /> �r Notary Public <br /> sNOTARY My Commission expires: 3 <br /> s cOj PJBvo g�a <br /> SIGNATURES MUST BE IN BLUE INK <br /> You must pptgt=ffMCRM:leM if3 at the location of the proposed mine site to clearly identify the site as the location of a <br />