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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 has been approved by the Mined 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 34-32.5-123, C.R.S. <br /> Signed and dated this (5 � day of 1-,)e L e y-v L U-- , 2_01V . <br /> l n 4 <br /> // Or7 U olU; + (U; - YY.,;X 'V K If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> 1 <br /> Signed: I 'dr' Signed: <br /> V T;:::' <br /> Corporate Secretary or.Equivalent <br /> Title: President Town/City/County Clerk <br /> State of Ob C OV4 ce 0 ) <br /> )ss. <br /> County of grim e/- ) <br /> The foregoing instrument was acknowledged before men this l 6 1- day of 6.0040-- n <br /> 201? ,by Vo/t - 1 h4A. it�J as Pi?cl of v� APV, ' L k_pdA. <br /> 0.1.!.go` / el) <br /> / Th4,. C C. <br /> 7 <br /> U,kOTAR y i t an hill ° 6.(2111-2-0 <br /> 000 i Notary Public <br /> �' t'UBOG, 6 <br /> vOFco\. My Commission expires: 02- -eg -,2-0 1 <br /> PAY COMMISSION EXPIRES <br /> February 08,2018 <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 />