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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 3432.5-115(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 applicantloperator, 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, C.R.S. <br />Thu form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.3-112,CR S, of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials Any alteration or modification of thisform .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.& <br />Signed and dated this 1 f h day of 5-<-1Z 4-e'n r .0, 01 —7 <br />Applicant/Operator or Company Name <br />Signed: �- <br />Title: Land Use Administrator <br />State of [ cc it 0 x <br />) ss. <br />County ofti� } <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />�l <br />The foregoing instrument was acknowledged before me this 11,41- ,� day ofk, �� <br />�a17 by as min ts,ra tpr <br />MINDY DUTRQ <br />Notary Public <br />State of Colorado Notary Public <br />Notary ID # 20134026866 <br />My Commission Expires 04-30-2021 <br />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 />