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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- 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)(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. 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.S- 112,C.RS., of the Colorado Land <br />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.S -123, C.R.S. <br />Signed and dated this day of , t [1 <br />Tiril �5�'r�ci�'c.' % S, If SQL <br />L ) Corporation Attest (Seal) <br />Applicant/Operator o ompany Name <br />Signe Signs _ <br />orate Secretary or Equivalent <br />Tit C,S' /l� jJ`I?�1! J Town/City/County Clerk <br />State of Q`r -�c� (3 ) <br />) ss. <br />County of LL..t^c ry4,,( ) <br />The foregoing instrument was acknowledged before me this day of r6,10 L'_ar -r_4_ , <br />rte, by i' •�.� S r' �� ii�•J as AtrY S'� d -!- of{-O tl !JIrQ l t:;S0LP _ 7.. c _ . <br />KELLi O MA ES Notary Public <br />NOTARY PUBLl <br />STATE OF COLORADO( �� 1 <br />NOTARY ID 20124084237 My Commission expires: \� <br />�pY_ �p�U1iNiSS1� ON EXi'IRES 3AN. 8, 2017 <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 />