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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 rmmimum <br /> requirements of the following terms and conditions: <br /> 1. To the best of my knowledge,all significant,valuable and permanent man-made struchur(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),CILS.). <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 1 misdemeanor pursuant to Section 18-8-503,CILS. <br /> This form has been approved by the Mused Land Reclamation Board pursuant to section 34 3I.S-11I,C.R.&,of the Colorado Land <br /> Reclantedon Art for the F-wreeddan of construction.Vaterials.Any alteration or modij?cadon of this form shall result in voiding any <br /> persrlt Issued on the altered or mod(fled fornn and subject the operator to cease and desist orders and civil penalties for operating <br /> without a permit pursuant to section 34-3!S 123,C.R& <br /> Signed and dated this day of <br /> Corporation Attest(Seal) <br /> pp li t Q1` Name <br /> c <br /> Sign Signed: — <br /> Corporat Secretary or Equivalent <br /> Title: Om*r Town/City/County Clerk <br /> State of I <br /> ss. <br /> County of— <br /> The <br /> foregoing instrpment was acknowled befi me this day of AG <br /> by as fkr ,,4c of d �rowe' <br /> LUCILLE REIMER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO Not public <br /> NOTARY ID 19%4014313 <br /> MY COMMISSION EXPIRES FEBRUARY 19,2025 <br /> My Commission expires: <br /> SIGI ATL ICES'-%I ST BE Eq BLUE LN-K <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 /> 14 <br />