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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 terns 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)(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)(1), 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 forur has been approved by the Mined Laud Reclamation Board pursuant to section 34- 32.5- 112,CR.S, of the Colorado Laud <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding any <br />permit issued air the altered or modifeed forne 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. RS <br />Signed and dated this ( -day of /✓D ✓v m6t?' _, � <br />Schlosser Incorporated <br />Applicant/Operator or Company Name <br />Signed: / <br />Title: Vice President <br />State of (lei L_Ia4_ � 1 <br />ss. <br />County of K4 cur5oq ) <br />If Corporation Attest (Seal) <br />j� �j �6f4� <br />Signed: /G� %� _k <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this day of - IV D v2 ki'% 6 <br />,,;b y � b m MOA as V'tc. re Si,UVLt-_ of 5CVJ o SJ'e-L <br />r .ACdrA6 <br />- � <br />KATHY DIANE SIMS <br />NOTARY PUBLIC <br />STATE OF COLORADO Notary Publi <br />NOTARY ID 19994009199 <br />MY COMMISSION EXPIRES SEPTEMBER 23,20T My Commission expires: &vf <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 />