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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) 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 -1 15(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. 1 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 b.y the Alined Land Reclamation Board pursuant to section 34- 32.5 -112,0 R.S., of the Colorado Lund <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding ally <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 6t 14, k r -� <br />_�— <br />Applicant /Operator or Company Name <br />State of <br />ss. <br />County of <br />The foregoing instrument w s acknowledged before <br />a_o�, by �� D . Zp-ju op-iD c 4$ <br />IL <br />Nom•. l�' F L I C•: <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Tot ✓n /City /County Clerk <br />day of <br />` ►212ICSA —1i Xj <br />Notary Public <br />My Commission expires: -91, /3 a10 1,7' <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 />