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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 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(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(4xf), 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 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,0 RS., 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 77:1;:t471:o4ffe,:ating <br />without a permit pursuant to section 34-32.5-123, C.R.S. ; <br />Via:: • ��,4� .� {-t � s'i <br />/1 day of DECE B� , �Q <br />Signed and dated this� � , ; • ''- �,wv °; ;, <br />Vit; - <br />o <br />A OP <br />If Corporation Attest (Seal}3 4 <br />r�, I ,'� Y? -re <br />1il' i y ..� r .4 1 <br />,.. i:. -7 - AO <br />LSigned: Signed <br />Title: V k --C - P E Sl Z-+.) T <br />MIS IPIUE- <br />Applicant/gperator or <br />ame <br />State of <br />.dolorado <br />) <br />� ) ss. <br />MM <br />County of c)l P Cron ) <br />,IS37 Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this 1.1 -Hr) day of 6C f PA <br />ice, by l . at as 11 P • a • of 1,-L1 {.l (C L1 k ,1 n. <br />itcolf -Mt!, <br />Notary Public <br />My Commission expires: 11!! q� 7 <br />SIGNATURES MUST BE IN BLUE INK <br />Vi',num l are•vsfomYi Cexnmrmmn 112 doe (Approved 05/1112005) <br />