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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. ' 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 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 ofLo TA , <br /> '-) Q0L'X_n If Corporation Attest(Seal) <br /> Applicant/Operator or Comp Ay Name <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: tom,-Q.,Y Town/City/County Clerk <br /> State of L 10 r&J 1) <br /> County ) <br /> of �� >>s. <br /> The foregoing instrument was acknowledged before me this Ord day of 7 .nC— , <br /> ,:;Lq4 by Chad (A.)r i# h 4- as 0aD",a Div n s n0A 8dg" of "#A-I1 2,41AIn <br /> CiEIRS..... ii���. <br /> P��'•Q'� �`•z p Notary Public <br /> Jj 0 <br /> s ai Z v o= My Commission expires: <br /> QJ,Q <br /> �'�•�r���/,''••..� �O����� SIGNATURES MUST BE IN BLUE INK <br /> T `\\ <br /> � ,�Z <br /> You most post suf�i�ll�,1lotices at the location of the proposed mine site to clearly identify the site as the location of a <br />