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-8- <br />Certil lea tion: <br />As an authorized representative of the applicant, l hereby certify that the operation described has met the minimum requirements <br />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)(c), 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 ofColorado 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 Art for the Extraction of Construction Materials. Any alteration or m adiflradon of diis fora shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and elv9 penalties for operating <br />without a permit pursuant to section 34 -32,5 -123, C.R.S. <br />+i. <br />Signed and dated this S ^ day of AvaV-s+ 7004- - <br />Nor Ia /oe-.Je %:,. If Corporation Attest (Sea)) <br />Applicant/Operator or Company Name <br />Signed: <br />Title: �r <br />Signed: <br />C rate Se�o4quivalent r E <br />State of a ,�--1-0 ) <br />) ss. <br />County of ) <br />The foregoing ins rument was acknowI dged before me this _ -= day of <br />a) by -- — ��� <br />Town/City/County Clerk <br />BRE.NVIA 4. McFARLANE Notary Public <br />NOTARY PUBLIC � Ink <br />STATE OF COLORADO My Commission expires: <br />My Commission Expires 1126108 <br />SIGNATURES MUST BE IN BLUE INK <br />.W-nirtftrv"fwym Cowiftyw ion 1124m (Appro nd 05i l U200) <br />