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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 />I. 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. 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 I 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 modif,catio,, 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 ; day of �f `• v , c / J • <br />C Co <br />Applicant/Operator or Company Name <br />Signed: .� �" ,� • - / t <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: C�,nr✓ictr '� (�13�.+�►1 _,t S� FE'Tj Can?) - Town/City/County Clerk <br />State of ('t()( <br />ss. <br />County of iL 1\ �G,\. ) <br />The foregoing instrument was acknowledged before me this `, day of J a t\ U a�( -1 , <br />1U1�.:,by 1�Ci\1 <br />• r' 1 l\0 ( as It�.,n,r.S 1.c,c,irii1%6,1e,. of Iii, , \.t (t ,t1 IA t <br />NotaryPublic `� <br />: y �h , {, -.\r <br />My Commission expires: 3 -) ( i Ir <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 />