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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(4xf),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. 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 fora[has been approved by the Mined Land Reclanntion Board pursuant to section 34-32.5-112,GR.S,of the Colorado Land <br /> Reclamation Act for the F—rac ion of Construction Materials Any aUeradon or nadrfwadon of this form shall result in voiding any <br /> perndt issued on the altered or nadified forn 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,GRS <br /> Signed and dated this day of 4 �L 'Z—'— v f <br /> if Corporation Attest(Seal) <br /> Applr�ant/Operator or CoTpany Name <br /> Signed: Z4 L7Signed: <br /> Corporate Secretary or Equivalent <br /> Title: Owner Town/City/County Clerk <br /> State of CV;dO ) <br /> )ss. <br /> County of 01r QG ) tt <br /> The foregoing instrument was acknowledged before me this t day of <br /> q ' by C n of <br /> MELLISA BLACK <br /> =•- •_ MYCOMMISSION#GG 274213 Notary Public <br /> EXPIRES:March 5� <br /> •.OF FLQP: 2�023 <br /> Bonow Thru NOW Public UrWWw,1W S / <br /> D 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 />