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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)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)(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. 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 Boardpursuant 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 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 permitpursuant to section 34-32.5-123,C.R.S. <br /> �.g <br /> Signed and dated this_�_day of —22a. <br /> If Corporation Attest(Seal) <br /> Applicant/Op for or Company Name <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: Town/City/County Clerk <br /> State of 12116 ra j6 ) <br /> ss. <br /> County of W e I ) <br /> The foregoing instrument was acknowledged before me this /S tK day of a ic, i`- <br /> 090// ,by Glt/veaL as COLLn :� j CF/) of i,,i W.c. reek.- ZwT- <br /> --o <br /> SHARON • Notary Public <br /> BENSON <br /> CP% ;. My Commission expires: 51,P4/-2 Ut <br /> 9jE.OF,Co`OQ� <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 />