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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 ofthe 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 Iaw <br />(Section 34-32.5-115(4)(0, C.R.S.; <br />3. As the applicant/operator, I do not have any extractiontexploration 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 CIass 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 34-325-111,C)LS, of lire Colorado Land <br />Reclamation Actfor the Extraction of Construction Materials. Any alteration or modykadon of this form shall result In voiding any <br />perndt issued on the altered or modiJ%d form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-32.5-123, CRS <br />Signed and dated this day of E_C_V, t,., �y F_11�— : --A. 0 i <br />� � CLS LJ6" JDL 01 �hys (� Lk <br />Applicant/Operato r Company Name <br />Signe, - - <br />Title: Road Supervisor <br />State of eo { Ea d 0 , <br />)ss. <br />County ofji ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or EquivalentY U <br />-TewWGiVCounty Clerk <br />The foregoing instrument was acknowledged before MA this o day of b' <br />by - 6DJ Rrt' as WD6Ct �i5 of 12� dt ��174 <br />DEBRA S. COWAN <br />NOTARY PUBLIC Notary Public <br />STATE OF COWRADO <br />NOTARY ID 20014039846 <br />MY COMMISSION EXPIRES DECEMBER 21, 2417 <br />My Commission expires: Dr ma)_ Lr � j 4017 <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 />