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-`t - <br /> Certification: <br /> As an authorized representative of the applicant, i hereby certify that the operation described has met the tninilnuln <br /> requirements of the following Icons 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 34-32.5-1 15(41(e).C'.R.S.). <br /> 2. No mining operation will he located on lands where such operations are prohibited by law <br /> (Section 34-32.5-115(4)(11('.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,('.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 ( misdemeanor pursuant to Section 18-3-503,C.R.S. <br /> This form has been approved hr the Mined Land Reclamation Board pursuant to section 34-32.i-/12,CR.S.,of the Colorado Land <br /> Reclamation:f et for the Extraction of Construction Materials. Any alteration or modification of this form s/tall result in voiding am <br /> permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties far operating <br /> without a permit pursuant to section 34-32.5-123,CRS <br /> Signed and dated this ! �es�^u u <br /> '.'�day •of �a/S <br /> II ('orporation :Attest (Seal) <br /> Applicant/Operator or Company Name <br /> "0Z-el—Signed: ia. %�! <br /> /{• b e.t ,4. rF.!l's Sighted: <br /> Corporate Secretary or Equivalent <br /> Title: See -c t«ey <br /> "Town/City/County Clerk <br /> State of a;‘,�k.vy.c.. ) <br /> ss. <br /> County of t t� ) <br /> I s- <br /> 'I'he foregoin' instrument was a--nowledged before me this day of J a-1 V <br /> 2015 1 /� <br /> by kDt+-4- 4. gay, r as Cccv.., of ( C vc.-4A+ <br /> /l./!/l./Y�llllllll./l1SEAL ll..11S ����� 1\�'I1���e <br /> +,.+++�,�. OFFICIAL SEAL <br /> k MICHAEL S HOLLIS ti <br /> ;art e NOTARY PUBLIC-INDIANA \ Notary Public <br /> O�t ,..� ALLEN COUNTY <br /> � ,•� My Comm.Ex.'res Nov. 18.2021 ' <br /> My Commission expires: I I le 202- <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 /> • <br />