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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 <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 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. 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 I 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,C.RS., of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of thisform 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 penal g <br /> without a permit pursuant to section 34-32.5-123, CR.S. <br /> uJ:"QQORq�� A <br /> Signed and dated this_ !2 _ day of Q <br /> _ �( ,iyt7/� •O <br /> ---cam ---- ;U ; <br /> DI c¢ca 5+1e S W Groot nc o oo <br /> rJ hn If Corporation Attest(Sea O%.�'ULORP° <br /> Applicant/Operator or Company Name <br /> Signed: ol _ Signed: 0�lo <br /> Corporate Secretary or Equivalent <br /> "Title. A, 5ec-, --- Town/City/County Clerk <br /> State of (elf;/ �t�f C� ) <br /> ss <br /> County of tfS� ) / <br /> The foregoing ipstrument was acknowledged before me this 1 4 day of d/L bet <br /> A_�&_, by_ -`_, e i' as _of 11Io4C451qr Sjt)(5,li fir- M . <br /> J GENEVIEVEN.BLECHA c'f bA upvvl ar Coe+�4tec' <br /> NOTARYPUBLIC <br /> STATE OF COLORADO Notary Public <br /> NOTARY 10#19914003259 rY <br /> My Commission Expires April 4,2019 4 <br /> My Commission expires: Age' o2©t�j <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 />