2017-09-20_REVISION - M1982155 (4)

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-8 - Certification: As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the following terms and conditions. 1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) inexistence at the time this application is filed, and located within 200 feet of the proposed affected area have been identified in this application (Section 34-32.5-115(4)(e), C.R.S.). 2. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-115(4)(f), C.R.S.; 3. As the applicantloperator, I do not have any extraction/exploration operations in the State of Colorado currently in violation of the provisions of the Colorado land Reclamation Act for the Extraction of Construction Materials (Section 34-32.5-120, C -RS.) as determined through a Board finding. 4. I understand that statements in the application are being made under penalty ofpedury and that false statements made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. This form has been approved by the Mined Land Reclamation Board parsuant to section 34-32.5-112, CRS, of the Colorado Land Reclamation Act for the Extraction of Construction Material& Any alteration or modifkadan of thisform shall result in voiding any permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating without a permitpursuant to section 34-32.5-123, CR.S Signed and dated this day of __:12 11 A v cjn L2 i. ; S _ If Corporation Attest (Seal) Applicant/Operator or Company Name Title: L% a _-- StateofSaprado 1 ss.County of ar,, Q ) The foregoing instrument was acknowledged before me this _LL, by SCO t — – as Signed: SIGNATURES MUST BE IN BLUE INK Corporate Secretary or Equivalent Town/City/County Cleric expires; u4aoh -)-