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W:10 <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. 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 Miner! Land Reclamation Boardpursuant to section 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation Actfor the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding any <br />permit issuer/ 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 sectiory 34-32.5-123, C.R.S. <br />Signed and dated this -D 1 day ofQ2- <br />r_ <br />n <br />0A19If Corpora <br />Applicant/O er for o ny Vame <br />Signed: FAQ "l `- Signe <br />Title: Town/City/County Clerk <br />State of U) ID rzF,t(),` j ) <br />ss. <br />County of Gso vfy\: A ) <br />The foregoing instrument was acknowledged before me this < day of LJ <br />22 b by C"ILi C E '.t1 C C(1(r <br />as _>9u kk0Aka " 1 t P ti 1 of - .,(U l 1•ti a <br />CYSJOANE. HORST <br />NOTARY PUBLIC Nota' Public <br />STATE OF COLORADO <br />NOTARY 10199441898R2i,2018 <br />MY( <br />PIRE6NOVEM6E <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK