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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_ 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 section 34-32.5-112,CR.S, of the Colorado Laird <br />Reclamation Act far the Extraction of Construction Materials. Arty alteration or modification ofthisforrn shall result in voiding any <br />permit issued on the altered or modified fora: and subject flee 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 } <br />r <br />If Corporation Attest (Seal) <br />Applicand pe dtor or Company Name <br />Signed: <br />T _ <br />Signed: . . <br />Corporate Secretary or Equivalent <br />Town/CitylCounty Clerk <br />State of Q� 4 ��) <br />ss. <br />County of <br />The foregoing instrument was acknowledged before me this day of <br />by .� 12V� .1Nu ---of <br />You mint <br />tloz `8 flif SHIM HOISSIM03 AN <br />BSZU+d00Z QI L MON <br />OGVX010310��HVIS <br />DIZSf1d X1'VJ(f&ATIIR <br />o.;t sufficciiaen,? VoIQIssr f Ill2c I ion of <br />RA_Notary Public V <br />My Commission expires: j j t 2_04-7 <br />MUST BE TN BLUE INK <br />proposed mine site to clearly ideRtify the site as the location of a <br />