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I <br /> - 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)inexistence 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 34-32.5-1 15(4)(e),C.R.S.). <br /> 2. No miming operation will be located on lands where such operations are prohibited by law <br /> (Section 34-32.5-t 15(4)(),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 Alined 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. .4ny 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 /> t 4z v <br /> Signed and dated this_f day of ..,_ ri _ i <br /> If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: ,� _ .t� Town/City/County Clerk <br /> State of 0-CC I c rad o ) <br /> }Ss* <br /> County of ) Apr( <br /> The foregoing instrument was acknowledged before me this day of f r(j � <br /> J � <br /> � ¢ by [L 1 �5 '� . lt°'�� as ., of :�r� <br /> KAREN SgAKI( Notary Public <br /> Notary Puttlir <br /> State at Calorado My Commission expires: <br /> Notary ID 20154047528 <br /> My Commission Ex ires Dec 10,2019 <br /> SIGNATURES MUST BE IN BLUE INK <br /> )'ou must pest sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a <br />