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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(4xe),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 applicantlopeiator,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 /> 77nis form has been approved by the Mined Land Reclmnadon Board pursuant to section 34-325:-112,CRS,of the Colorado Land <br /> Reclamation Actfor the Fidracdon of Consturucdon Materiels. Any adenadon or nwd kadion of Anform shall result=voidwg any <br /> permit issued on the altered or mod#W form and subs the operator to cease and desist orders and civil penalties for operating <br /> without a permit pursuant to section 34-325-123,CRS <br /> TH <br /> Signed and dated this day of ,J ily g— 7 Q -- <br /> Wyatt Redi-Mix Company If corporation Attest(Seal) `\ <br /> Applicant/Operatorpr Company N f� <br /> Signed: - �` Sign <br /> Corporate or Equivalent <br /> Title: President(Vice-President Town/City/County Clerk <br /> State of Colorado ) <br /> )ss. <br /> County of Jackson ) <br /> The foregoing instrument was acknowledged before me this q day of <br /> . �_4,k as Pres&11,+ 4 SgcrjA" of Wyatt Redi-Mix Company <br /> Notary Public <br /> ,� tY P(le My Commission expires: 5h o to <br /> AMANDA L <br /> S SIGNATURES MUST BE IN BLUE INK <br /> You m ••�� Vu at the location of the proposed mine site to clearly identify the site as the location of a <br /> My Coma on Expires 05/1012016 <br />