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-8 - <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) 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 form Juts been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.R.S., of the Colorado Laurel <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form 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 30 day of /i.i U. �Qj•5 <br />Coulson Excavating Co., Inc <br />Applicant/Operator or Company Name <br />Signed: kr:.e...—^ <br />Title: President <br />State of t✓,-, l,, ick p <br />) ss. <br />County of tok-i INt z ) <br />If Corporation Attest (Seal) <br />nThe foregoing instrument was acknowledged before Cme thisZ1/141,____day of <br />7..015, by ,�y.1.1 4- art�Sn,J as t__C--.S,,AF►a-V' <br />er ,c<N; <br />' : -<;; <br />3� <br />5, A LBLIIC ..O <br />litrirrlm:/r pt,�, <br />Signed: <br />Corporate Secretary or Equivalent L/ / 4i <br />Town/City/County Clerk <br />of <br />Notary Public <br />My Commission expires: ..) 1-&J2 <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 />