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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(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(4)(f),C.R.S.; <br /> 3. As the applicant/operator,I do not have any extraction/exploration operations in the State ofColorado 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 Reclamatlon 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 ofthis 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 permit pursuant to section 34-32.5-123,C.R.S. <br /> Signed and dated this ' day of l'k-t-)� (t' <br /> 61ICI'r' e 1 1j7� . If Corporation Attest(Seal) <br /> Applican Operator or Company Name <br /> Signed: :2� ks ffitt Signed: <br /> Corporate Secretary or Equivalent <br /> Title:al 1 Oul�'Jc'r Town/City/County Clerk <br /> State of O N It,-&do <br /> n <br /> County of { 1 a,TP 5 )Ss. <br /> The foregoing instrument was acknowledged before me this day of X4 l <br /> OXLI& by�j�-rr as of T, 6 h S <br /> RANDALL D.SCHAFER A/ ` LI t' -A C re <br /> NOTARY PUBLIC <br /> STATE OF COLORADO Notary Public <br /> NOTARY ID 19954016062 / <br /> MY COMMISSION EXPIRES 12/06120t6 My Commission expires: <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 />