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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 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 34-32.5-115(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. 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 fora: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 modiftcation of this fora:shall result in voiding any <br /> permit issued oil the altered or nlod fedfornj and subject the operator to cease and desist orders and civil penalties for operating <br /> ivithout a permit pursuant to section 34-32.S-123, C.R.S. <br /> Signed and dated this— _day of �o <br /> S If Corporation Attest(Seal) <br /> Applicant/ perator 4C=pany Name ' <br /> Signed: Signed: 6 <br /> Corporate Secretary,of Equivalent <br /> Title: Town/City/County Clerk <br /> State of <br /> )ss. <br /> County of r f ► _) <br /> The foregoing instrument was acknowledged before me this 9 day of ' <br /> by--:Dtbel ! d ! f2���.� �"eStrt�?�t� h?."S <br /> VIA <br /> Notary Public <br /> RANDALL D.SCHAFER <br /> My Commi FmCOMMISSION <br /> expSIC <br /> TATETOP COLOARY LRADO <br /> NOTARY ID'19954016062 <br /> SIGNATURES MUST BE IN BLUE INK EXPIRES 12/0612016 <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 />