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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. 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,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. ���•`,PV EL <br />F <br />Signed and dated this 1 day of �01�tx��� = •C9 <br />k GORPORATF•• G. <br />Pine Bluffs Gravel & Excavating, Inc. If Corporation Attest (5- CD t) �- <br />Applicant/Operator or C pan ,..(3 <br />�. <br />oil <br />Signcd: Sign : ✓ <br />Corporate Secretary orEquAlent <br />Title: I�f �� �. Town/City/County Clerk <br />State of Wyoming ) <br />ss. <br />County of ) <br />The foregoing instrument was acknowledged before me this day of QoOtA-,.�,,._ <br />by as of Vi C- ya,,L� <br />CS Ex ca oo A <br />DEBOMAH t.. MOMGAN -'NOTARY PUBLIC <br />COIJId'r` OF STATE OF otary Public <br />ORAMIE WYOMING <br />My commiasioo " res j 2a - _ 1 G My Commission expires: I <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 />