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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 stmucture(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 3432.5-115(4)(e),CYLS.). <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 secdon 34-325-112,C LS.,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 /> permh 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 34-315--123,CR.S <br /> Signed and dated this Z-d day of Z_ .,,}L <br /> S vz xa n 6=5 J=L G If Corporation Attest(Seal) <br /> 4pli4aOdperator or Company Name <br /> Signed: Signed: <br /> l Corporate Secretary or Equivalent <br /> Title: �t-E,s; c Town/City/County Clerk <br /> State of <br /> )as. <br /> County of (�Vt�/� ) <br /> The foregoin�j�instrument was acknowledged before me is 0U day of, 2 D/& <br /> .by AF OA /��I t°r as �e511le'/�t of`Svr ,956 4-1265Ap l <br /> jr <br /> JODI Cox Notary Public <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY 10 20144022503 My Commission expires: <br /> W COMMISSION EXPIRES JUNE 5,2018 <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 /> I,l,2el/ <br />