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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 Boardpursuant 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 olQ f)13— day of ELI 16 4J <br />A C Pn am - r- 661 A tt& o .0 . l�i2„ .,n e <br />Applicant/Operator or Company Name <br />Signed: Al c <br />C <br />Title: ALA.," <br />State of C-0 t-aA ) <br />\ 1 I /� ) ss. <br />County of fc.� r l e —cc n ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />rl�) <br />The foregoing instrument was acknowledged before me this ���� day of 'Wird R 1- <br />���1:> , by wlft a'l GFW ' lE� <br />as t11G;1Gi..11(�lti l�lllt:�i' of <br />JILL MASTERS Notary blic <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />>" r"RY ID * 1997401095' ' C- I '] <br />- - �Y°IREs J1 t� My Commission expires: / / <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 />