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IHI <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)0, C.R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State ofColorado 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 jar 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 Z 7 day of T Z L-,// . <br />If Corporation Attest (Seal) <br />Applicant/OperatorAr Company Name <br />Title: <br />State of Co Iyrud b <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />ss. <br />County of is s A tt i rvx �S <br />The foregoing instrument was acknowledged before me this 2.J th day of4P V! <br />Zgy, by GR!N D. 14( t as �kt MCW\ of Baa -rd &' COYMVK1s510 AefS <br />J <br />ERLY A. CHAVEZTARY PUBLICNot Public <br />E OE COLORADORY ID 19984014199ON EXPIRES JUNE 03, 2018 My Commission expires: 3 8210 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 />