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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 1 misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34- 32.5- I12,C.R. S, 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 modifred 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 I l day of 'T Ck y� L 0(_ K t , � C) , ` <br />Applicant/Operator or Company Name <br />Signed: �--- --- <br />Title: <br />State of U / d t " ",tal (') <br />)Ss. <br />County of 1-' 1 <br />�a:� ) <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 10h day of .J0_ 0 U Q i'4 , <br />,)t:11 5 , by 1) ) i' (-- 1)a,,1 a-t'! 6 r arcy as c co of l orlc'cr <br />ENOTARY RLY KRETZ IR <br />ARY FUIUC <br />OF COLORADO <br />O 20030311 BO <br />oh EapMa Ot- 17.2017 <br />Notary Public i <br />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 />