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-8- <br />'ertification: <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 />'Y� cr\ <br />fined and dated this <br />day of It \) (,\ <br />O_D ec, <br />Applicant/Operator or Company Name <br />Signed: <br />Title: <br />State ofC0IOr` 0 ) <br />) ss. <br />County of 0 RSIV R n ) <br />, Qo <br />If Corporation Attest (Seal) <br />Signed: - <br />C <br />The foregoing instrument was acknowledged before me this day of 40 <br />'7)l0IC, by Sc_i, nQ oQ1 as Pr,,.N►2n- <br />0/111114E GRACE NG <br />WARY <br />10401 F <br />NOM' q 20101011714 <br />-MY COMMISSION EXPIRES MAY 7, 2011 <br />ary or Equivalent <br />Town/City/County Clerk <br />of c -vel;* mi i, Cor,C1'f-4`; C. o , <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />rn <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 />