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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 witWn 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 applicantloperator, 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 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 F-draction of Construction Materials. Any alteration or modification of thisforin shall result in voiding any <br />permst 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 / AAA-- day of <br />Comf r4tQ <br />Coulson Excavating fie:, Inc If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />l� <br />Signed: Signed:''- <br />Corporate Secretary or Equivalent <br />Title: President <br />State ofle ) <br />`` ) ss. <br />County of C c✓- - PJ- ) <br />The foregoing instrument was acknowledged before <br />. by A)e — C� L -a as <br />CA <br />= C <br />COLORPO� <br />Town/City/County Clerk <br />My Commission expires: i - 2'n 1 I <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 />0 <br />