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We <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)(c), 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. 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 I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Boardpursuant to section 34-32.5-111,C.RS., 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 modifed farm and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-32.5-113, CR.S <br />Signed and dated this day of , <br />Applicant/Opemtor or Company Name <br />Signed: <br />Title: e*e.&�4 it <br />State of 2Z Zoe e 0/a <br />ss. <br />County of -t ) <br />If Corporation Attest (Seal) <br />4Z, 0op <br />0 <br />W SEAL m <br />S 2005 y <br />O <br />:cretary or Equi; *lent <br />own/City/County Clerk <br />The foregoing instrument was acknowledged before me this day of <br />9,M& by I --_as 1'r +ra of <br />-- <br />--�-••�• }O'!!C/A�� lid C <br />11, <br />1A fE0 li LV;�{ , Notary Public <br />NOTARY T) I9 5411=61 <br />V1 07MISS1OH EXP ;tea OECEMBrx 52, 2020I My Commission expires: J 2 2 as z <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 />