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1 <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minitnutn <br />requirements of the following tenms 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 />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This fornt has been approved by the alined Land Reclamation Boardpursuant to section 34-32.5-112,CR.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction alaterials. Any alteration or modification of this forst 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 3 day of Gc 6'-a u y 2 1 s <br />1-d l d 'f -f- C-0-1 JT'e w C t0'* r1 " , Ile- <br />Applicant/Operator or Company Name <br />Signed: y u <br />Title: ;eC-eC rar//-f -,,-eFrt - Cr <br />State of M •,. ) <br />ss. <br />County of 1 t r1 ) <br />If Corporation Attest (Seal) <br />Signed: ` • <br />71r <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoin i trument was ac owledged before me this <br />d <br />day of -F, <br />V_ as S« v - / .S of Lo <br />Lt l <br />OFFICIAL SEAL <br />y MICHAEL S HOLLIS Notary Public <br />rENOTARYPUBLIC - WMW JOOALLENCOUNTY <br />Nov. 18, 2021 My Commission expires: l I uZ <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