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-8- <br />Certific tion: <br />As an a thorized 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 of the proposed affected area have been identified in this application <br />(S ction 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)(1), 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 />(Suction 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 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 is ued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating <br />without permit pursuant to section 34- 32.5 -123, C.R.S. <br />Signed and dated this l2 -" day of —_y.s ,-► � , Z o k,+ , <br />Applic nt/Operator or Company Name Se, - 4 <br />Signed: <br />Title: <br />State of L,010 9/C) ) <br />ss. <br />County of- �� ✓��) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate S cretary or EquNalent <br />Town/City /County Clerk <br />The for 'going instrument was acknowledged before me this day of <br />C , <br />PEGGY E. RIPPY <br />NOTARY PUBLIC Notary u I' <br />STATE OF COLORADO <br />NOTARY ID #19964016779 My Commission expires: & .Sr a014�c <br />My Commission Expires November 5, 2016 <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 />