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-8- <br />Certi_fieat�: <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(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. I understand that statements in the application are being made under penalty of perjury and that false statements <br />trade 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 Boardpursuant to section 34-32.5-112,C.R.S., of t/re Colorado Land <br />Reclamation Act for the Extraction of Construction Alaterials. Any alteration or modification of this form shall result in voiding tiny <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for coerating <br />►vithout a permit pursuant to section 34-32.5-123, C.R.S. <br />ra <br />Signed and dated this 3 r� day of Ft b" a '7' , z 1 s <br />Applicant/Operator or Company Name <br />Signed: <br />Title: '�etrGre, ry/'itaSr-er <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of . -1,n c #A n •.. ) <br />_I,_ ) ss. <br />County of �-i 1 t f ) <br />The foregoinAiriptrument was ac owledged before me this r d day of <br />1P f S, by feobf as Jlc- 114A- / S v -ir of <br />OFFICIAL SEAL Notary Public <br />MICHAEL S HMLIS <br />NOTARY PUBLIC - INDWA <br />e AALLEN COUNTY , <br />Nw. 18, My Commission expires: l I -Z <br />SIGNATURES :MUST BE IN BLUE INK <br />You must post sufficient Notices at the location of the proposed trine site to clearly identify the site as the location of a <br />