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-8- <br />Certifieation• <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following teals 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 fat ofthe 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 3432.5-115(4)0, C.R.S.; <br />3. As the applicantloperator, I do not have any extraction/exploration operations i n 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 arc 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 />lU form has been approved by the Mined Land Reclamaden Board pursuant to sedfae 34-32-S-112,GItS, of the Colorado Land <br />Jtedamadou Ad jar the Edracdom of Carsfrrrdfoa Matedals� Any afferadon ar mog lcadw of skis farm shall result in valding say <br />permit issued an the altered or n" led farm and subject the operator to erase and daW orders and civil penalder for operadag <br />without a permit pursuer to section 34-33.3-123, CRS <br />Signed and dated this � f N day of G b,cf .2017 <br />to COJA , �Omgi- r <br />Applicant/Operator or Company Name <br />Tide: Land Use AdmMWtmWr <br />State of COW ajQ j <br />)sq. <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/C2EDtLCIerk <br />County of 1 i Y) ( h I ki_ _ _ : } <br />The foregoing instrumentwas acknowledged befare me this l day of C " <br />Zr� by _ _as �111f g drain �Cal,or I C 4 <br />MILADY DUTRO Notary Public <br />Notary Public <br />Stat* o1 Colorado <br />Notary ID020134036858 My Commission expires:rift <br />V d <br />MY Commission Ex Ires 04-30.2021 <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 />