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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(4xe), 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(4xf), 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- 112,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any 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 <br />�.FUU /sC L/� . <br />1� f ./t /L-- L- 1%ki% ,S" L�//c 1-t.// %f If Corporation Attest (Seal) <br />Applicant/Operator oyCom(any Name <br />State of (—_C) t l)rr'-J O ) <br />f _ SS. <br />County of t�G_�t nt�V' ) <br />JOAL . <br />.� rite Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this -T in <br />-- day of r&- <br />by t'.� 5{ q�uL:� as_Prt S'�d &A4- of SAXU()! I &OL'5vl.1, Yr —. <br />!''C'E' LLI O MAES Notary Public <br />NOTARY PUBLIC <br />NpATAR OD 2012 p84D9 <br />MY CpiNMiSSIOtJ EXPIRES JAN. 8, 2017 <br />My Commission expires: �h -z© t <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 />