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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. 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 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. <br />q qe- <br />Signed and dated this (0 day of PGC&X-tai4_ 01 <br />16sco cm u t'Fmb S wCAS 4V-- If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Title: Q�1�l4.1L- <br />State of ( y h[ (Z CID ) <br />) ss. <br />County of W e -AA ) <br />Signed <br />Corporate Secretary or quivalent <br />Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this 1g� day of e mhe e , <br />aQA_, by r`r 0Y)ak- l fr � e✓ as -(tL r� e of VeS-07- j I"I�Ce� li[ <br />TARA BRISBY Notary Public <br />Notary Public <br />State of Colorado <br />My Commission expires: <br />My Commission Expires January 06, 2015 <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 />