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1 <br />1 <br />Cerdflcadon: <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) 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)(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)(0, C.R.S.; <br />3. As the applicantloperator, 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 fording. <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 I misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Boardpursuant to section 34- 32.5- 112,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials.,lriny alteration or modification of thisform 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 />Signed and dated this day of f <br />Or A 11 n 0. r k^_ 'It f -A ve. <br />' Applicant/Operator or Company Name <br />Sipe;;_;lz_ <br />i� <br />n <br />1 <br />Title: A <br />State of CAO�Z <br />�— If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />Cou <br />The fore oin ins ment was acknow edged before me this '-1 day o <br />by` lr t V�c+ ✓ as AACAA of <br />Notary Public <br />My <br />NOTARY PUB <br />B — <br />STATE OF COLORADO <br />SIGNATURES MUST BE IN BLUE NOTARY ID 19964010720 <br />ZY "COMMISSION EXPIRES NOVEMBER 18, 2016 <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 />