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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 34-32.5-115(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 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. 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 Reclamation Board pursuant to section 34-32.5-112,C.R.S.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this 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. <br /> S.Signed and dated this day of� C c M b a r— <br /> Ieq A / H Mrn�h C U L L 6- If Corporation Attest(Seal) <br /> Ap cant/Operator or Company Name <br /> Ja/,,. f R M v flr A `7 <br /> Signed: Signed: <br /> ell Corporate Secretary or Equivalent <br /> Title: /111?0 n 4 g r-7 tg Town/City/County Clerk <br /> State of 4:�2 l/)l n 4 �? ) <br /> ss. <br /> County of � � Sv�'i ) <br /> The foregoing instrument was acknowledged before me this f S� delay of� M <br /> ZoI7 , by )ti of ) ti d7v n."'A L( <br /> ANTONIO G MARTINET_ Notary Public <br /> NOTARY PUBLIC <br /> STATE OF COLORADG My Commission expires: <br /> NOTARY ID 20084033351 <br /> W COMMISSION EXPIRES 09/24/20 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 />