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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 Actfor the Extraction of Construction Materials. Any alteration or modification of this fonn 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 1 / day of .4) On (V/ G (9 / . <br />Co% rJ. s%.ne.- Qud1.•►PIegg =In c. <br />Applicant/Operator or omppity Nam <br />If Corporation Attest (Seal) <br />Signed- '��� Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />Title: `ENC fAL 1'01 Xek <br />State of GO 1 O ra. A f3 <br />11 ) ss. <br />r <br />County of Q�,C �`et<s <br />The foregoing instrument was acknowledged before me this 12- day of J0.41 UQX' <br />20LLQ, by Dan i.¢,14. T ev 5 as • ' I t , if d. t ! of Cdtea dd . Ori e <br />ilk in t qto r r 1 S <br />ANA B GARCIA <br />Notary Public <br />State of Colorado <br />Notary ID 20064051013 <br />My Commission Expires Dec. 22m, 2018 <br />I <br />Public <br />My Commission expires: /7122 /1- <br />RES 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 />