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i <br /> 1 -8- <br /> ICertification: <br /> As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br /> Irequirements 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 /> I (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 /> I (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 /> I (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 /> Imade 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 /> I 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 /> IIISigned and dated this _day of J f <br /> S l <br /> T i r >1 cti v\ Gc w (`�/'�1 VC.l Co-If Corporation Attest(Seal) <br /> IApplicant/Operator or Company Name <br /> ISigneL Signed: <br /> rm Corporate Secretary or Equivalent <br /> Title: Gi vt c 3Y(^/ Town/City/County Clerk <br /> State of`(--1QS(.tip ) <br /> 1 Couky o ) <br /> nnol� <br /> The foregoing ins ment was acknow edged before=Z., day o C� <br /> 1 ,by� e ��G✓ as e of V LA(AAA L n <br /> licf. C.--i Notary Public <br /> I _ <br /> k' NOTARY PUBLIC <br /> STATE OF COLORADO <br /> SIGNATURES MUST BE IN BLUE Il� NOTARY ID 19964010720 c, <br /> I Y COMMISSION EXPIRES NOVEMBER 18,2016 S <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 />