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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 pennanent 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)(c), 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, l 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 Extraction of Construction Materials. Any alteration or modification of thisform shall result in voiding ally <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 It S <br />VOL V- rix C0(VV P a A i�S, _i�_rtc.. <br />Applicant/Operator or Company Name <br />Title: 1'.(, <br />State of 0 o I o rad D l <br />ss. <br />County of We_1d ) <br />If Corporation Attest (Seal) <br />Signed: <br />Co orate SeUetary or Equivalent <br />Town/City/County Clerk <br />The foregoin instrument was acknowledged before me this Uday ofjuS-t" , <br />by - rrckt V0..rrq as V. of Vaytr nth <br />JESSICA HOOVER a&nA=2 <br />NOTARY PUBLIC No Public <br />STATE OF COLORADO <br />NOTARY ID 20044035571 <br />M Commission res Oct. 4, 2016 My Commission expires: 10 <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 />