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-8- <br /> Certification: <br /> As an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements <br /> 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(4xe),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(4xf),C.R.S.; <br /> 3. As the applicantloperator,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 34-3Z5-112,C.Jt&,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modUkation of this form shall result In voiding any <br /> permit issued on the altered or modUled form and subject the operator to cease and desist orders and civil penaitks for operating <br /> without a permit pursuant to section 34-32.5-123,C.lt S„• <br /> Signed and dated this _C20 day of Fe. r�-P-r.. U� <br /> C. r: li COV", If Corporation Attest(Seal- <br /> ApplicantlOperator or Company Name <br /> 7 <br /> Signed: �`-�'�""• Signed <br /> Corporate Secretary or Equivalent <br /> Title: N kC'q: S\% �J� Town/City/County Clerk <br /> State of �rCLtAiO l s } <br /> ss. <br /> County of LOOK _) <br /> The foregoing instrumcnt was acknowledged before me this day of JAESR VACY <br /> 46d,by SUf as Y of&MAISAI r A '�t'/Al3 c.ZidK <br /> r�rtlG� <br /> M 6_ 1f001 Do N Notary Public <br /> r InamerAWOM <br /> My Commission expires: <br /> SIGNATURES MUST BE IN BLUE INK <br />