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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 thisform 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 permitpursuant to section 34-32.5-123,C.R.S. <br /> Signed and dated this day of 1�) <br /> If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Z <br /> Title: .``1 �i s;� i ._: 'i' Town/City/County Clerk <br /> State of U 0roao ) <br /> County of I.-t Rol Ill )s <br /> The fore Loin ins'''t�ru""'m� ""e""nt was acknowledged before me this `1 day�,o�f" , <br /> �,by e U1(�1(,t -Clo►GI v1S as__�L�(Y�UIr!�C11 T�(.!(r�V Ili� of � <br /> LLL? <br /> JOEY RHODES <br /> NOTARY PUBLIC Nota;ryPdiic <br /> STATE OF COLORADO <br /> NOTARY►D 20174032666 <br /> MY COMMISSION EXPIRES AUGUST 3,2021 My Commission expires: C 1312t <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 />