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- s - <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)(0,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-II2,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 day of OC.1 C)/ (e <br /> yi!1/l4 OL'0 ni!q If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> Signed:L_ � Signed: <br /> Corporate Secretary or Equivalent <br /> Title:)?cel PrvtbTI0 L9 141 A-, q G S F-c71-1 00`a Town/City/County Clerk <br /> S <br /> State of L I ,;j ) <br /> ) ss. <br /> County of 1: II_)-Q ) <br /> The foregoing instrument was acknowledged before me this r l day of �- <br /> a , b- of / LJ( t cr-"a L__knt" <br /> DEBORAH LEA LOGUE <br /> NOTARY PUBLIC-STATE OF COLORADO Notary Public <br /> Notary Identification#20154045671 <br /> My Commission Expires 11/24/2019 <br /> 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 />