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rm�� <br /> r}d RECEIVED <br /> 1��� <br /> DEC 1 2016 <br /> -8- DIVISION OF RECLAMATION <br /> Certification: <br /> MINING AND SAFETY <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 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 I misdeirleanoUursuant to Section 18-8-503,C.R.S. <br /> This form has been approved by the Mined Land Reclamation Board pussuaw to section 34-3Z5-112,C.R.S.,of the Colorado Land <br /> Reclamation Act for Ilse Extraction of Construction Materials Any alteration or modification of thisform shall result in voiding any <br /> permit issued on the altered or modifsed forns and subject the operator to cease and desist orders and civi/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 /> v Rry, tr.�>1�! If Corporation Attest(Seal) <br /> Applicant/Operator or CompanytName <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: L<arlt, .r'�q ��f` Town/City/County Clerk <br /> State of Co�oty 1 <br /> )ss. <br /> County of r�4r K ) <br /> The foregoing instrument was acknowledged before me this day of , <br /> o?D1 L,by ga m;e.f f 4,jrur as -1c"S21 jerr ,n.,.epr of <br /> GREGORY D.KASPAREK Notary Public <br /> NOTARY PUBLIC <br /> STATE OF COLORADO d2U 2v <br /> NOTARY 0 20104012M My Commission expires: r, <br /> MY COMMISSION EXPIRES April 1,2020 <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 />