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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) 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 />(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 1 misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />This form has been approved by the MlWedLand Reclamation Board pursuant to section 3¢32.5- 112,C.RS, of the Colorado Land <br />Reclamation Adfor the Extraction of Construction Materials. Any afteratlon ormod#?cadon ofthic form shall result in voiding any <br />permit issued on the altered or modyied form and subject the operator to cease and daW orders and ctWpena&ft for operadng <br />without a permit pursuant to section 3 123, CA& <br />Signed and dated this . aCY day of 00 <br />no of <br />Applicant/Operator or Con1pany Name <br />Signed: 40. <br />State of O-q U1 b ) <br />ss. <br />County of w �� ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this Imo— day of k yC _ A <br />00 <br />by k �t3WZ92V. as O Cs.x. cs-Do K60-1 of VdZcMO]� <br />`c mac• Q) CW Q <br />TRICIA DAVIS Notary Public <br />NOTARY PUBLIC <br />STATE OF COLORADO My Commission expires: <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 />