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WE <br />CertWeation: <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) inexistence 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. 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 />This form has been approved by the Mined Land Reclamation Eoard pursuant to section 34-32.5-112,0.&&, of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials Any alteration or Modyicatdon of this form shall result in voiding any <br />permit issued on the altered or modffled form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit parsuant to section 34-3ZS-123, C.R S <br />Signed and dated this day of <br />YA ;/0/, -Z 114 M116 -5 71) 46/4c— <br />Applicant/Opem r or Co y Name <br />Signed: <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: Town/City/County Clerk <br />State of ��►(-�"",y V�- Ab yfm� <br />ss. <br />County of The foregoing i ent was acknowledged before me this day of <br />. by of <br />Itfil31l P VAIDl1M <br />NOTARYPUNA <br />SrATEOFCOLORADO Notary Public <br />NOTARYm 20131615M <br />WYCOhYAfMMEXPRMAIJtiWS, 2021zI <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 />