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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) 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 applicantloperator, 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,CR.S., of the Colorado Land <br />Reclamation Act for tine E.Ytractioir of Construction Materials. Airy alteration or modification of this fornn 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 o permit pursuant to section 34 -32.5 -123, C R.S. <br />Signed and dated this . .-a <br />-- -2 / u day of <br />-A Li i,ftij lt4I,ri {`,14,2. lvi - eitry[.��, <br />Applicant/Op <br />orajor or Company Name <br />,i �� ~ i' ✓ <br />Signed:, <br />Title: <br />State of <br />) ss. <br />County of �l c 41-Y I ) <br />If Corporation Attest (Seal) <br />Signed: �-- <br />Corporate Secretary or Equivalent <br />Town /City /County Clerk <br />The foregoing instrument was acknowledged before me this 5� day of �Gt� ,z ao tl <br />by - ,134L1Q' , /,r�- as l)( ilc.51 1'J-1 },'es't errf of Cl/lif r sue, Y/l� f -� 7 z <br />E „M' Not Public <br />'IVOTgR'�Gt�_ <br />My Commission expires: ?� <br />Ic <br />SIGNATURES MUST BE IN BLUE INK <br />'���4p��OLORQ�``' <br />