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-8 - <br />Certification: <br />As an authorized representative of the applicant. 1 hereby certify that the operation described has met the minimum <br />requirements of the following_ terms and conditions: <br />1. To the best of nay 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 34-32.5-11.5(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 has been approved by the Alined 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 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 3.1-32.5-123, C.R.S. <br />Signed and dated this <br />day of S ( ` L , . 74` 1 . <br />cjC.fri If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Signed: <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: 4. elAv cTii,'-) 'N1 S;,1 F E'r j Ca*'r . Town/City/County Clerk <br />! <br />State of It () t (> ) <br />ss. <br />County of `(,\ ) <br />The foregoi1ng instrument was acknowledged before me this `.> day of J (1 (\ U. a ( <br />161L, by l)C: r \ h \Gt C- as \',4\', r. (c'0rr i\G. G, of `int <br />.1 <br />Notary Public <br />(Ott t C( <br />il_�,2I <br />.l' <br />My Commission expires: ( 3 )(,1 (- <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 />