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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has indthe mitunnnn require npSts of <br />the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man -made strucu re(s) inexistence at the time this <br />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 arc prohibited by law <br />(Section 34- 32.5- 115(4Xf), 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 made <br />herein are punishable as a Class I misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />Tbla fora has been approved by the Mined Land Reriamatdon Bowd pursuant to section 34- 32.5 -112,C U,•of the Colorado Land <br />Reckmalum Actfor the Extraction of Consb�uction Materials. Any aEteratim or msod�ion of tkis form shalt resadt in raidf '#Ry <br />permit issued on the aLfrred or n�oa red form and subject the oywarm to came and desist orders and cirdi Obis i # ° r <br />a pow*pwmant to sec on 34 -32.5 -123, CRS . f" oPa d xtbi+out <br />v <br />Signed and dated this Z day of <br />If Corporation Attest (See!} <br />Applicant/Ope�gor or Company Name <br />G .1 Y. - �TF= <br />Corporate Secretary or Equivalent <br />Title. IL R-21M ?29 5 •.s �'q= Town/City/County Clerk <br />State of l:nlo TIt7 <br />County of wet DL 1 <br />The foregoing instrument was acknowledged before me this day of —`-"— , <br />by P. g r g aS _ \n.. v5 1 Pr- of <br />AMA00 •o �18n•.. ¢ No i&, Public <br />)kW.in1shwevWo m1Conwuaion 112 doe (Approved 05111 <br />y Commission expires: L0,4V a <br />INK <br />