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-8- <br /> Certif milim: <br /> As an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements <br /> 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(4xe),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 applicantioperator,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. 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 Mixed Land Reclamation Board pursuant to section 34-325-1lZC.JRS,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials Any alteration or modijicatfon of this form shall result in voiding any <br /> permit issued on the altered or modem form and subject the operator to cease and desist orders and civil penalties for operating <br /> without a permh pursuant to section 34-32.5-123,C.R.S. <br /> Signed and dated this day of 19 <br /> 1'/�r►?on 12r)J'de"at '07";C' If Corporation Attest(Seal)_ <br /> Applicant/Operato r Company Name <br /> Signed: Signe <br /> / L orporate Secretary or Equivalent <br /> Title: Lei-,Or'Ut T Town/City/County Clerk <br /> State of /�o <br /> )ss. <br /> County of J� �. ) <br /> The foregoing instrument was acknowledged before mcthis <br /> day of J414AI _ , 2,g a91/ <br /> �>by _�� r`�r��GirbT ofx�2 r.lK <br /> DEli13E: M7AlEi _ � <br /> NOTARY FU911C <br /> STATE Of COLORADO, <br /> my rssron ues 0 No ry Public / <br /> My Commission expires: �f'7;��/'d <br /> SIGNATURES MUST BE IN BLUE INK <br />