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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)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)(0, 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.S. <br /> Signed and dated this �3 day of C;)a! <br /> J. <br /> (.X nf. of-tAMo54- If Corporation Attest(Seal) <br /> Applicant/ erator or Company Name <br /> Signed: Signed: oao t.w, 24, <br /> -y -"�""'ttic� <br /> ,Q Corporate Secretary or Equivalent <br /> Title: 2 T S ;r44j6V-1 Town/City/County Clerk <br /> State of L d'GD04 2)d ) <br /> ,,�/�J �- )ss. <br /> County of A4,oWzfur . ) <br /> The foregoin instrument was acknowledged before me this day of <br /> by �+cK X' s0CxtgWAY as of u" , Co. �^S. <br /> EPATRICIA p N BRINKNotary Public <br /> TARY PUBLICTE OF COLORADO964 <br /> r ID 2 p 18-20 00 My Commission expires: 7 a�ad <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 />