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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 this form shall result in,viilling any <br /> permit issued on the altered or modified form and subject the operator to cease and desist orders and civil pen ilt�e4 ji in e3atirtg <br /> without a permit pursuant to section 34-32.5-123,C.R.S. O <br /> Signed and dated this 2.4 day of \q0.4 e r , 201D . <br /> ('IV 3S a <br /> 11-1CO L. nurt4 If Corporation Attest(Sear). A' .. Oar <br /> Applicant/Operator or C�mpany Name "••, ,O,t N, <br /> Signed: . L/_ _ Signed: <br /> t Corporate Secretary or Equivalent <br /> Title: l,�a}.,et Use r Town/City/County Clerk <br /> State of C 0/orad o <br /> )ss. <br /> County of LIQ C01 i1 ) <br /> n <br /> The foregoing instrument was acknowledged before me this O? day of C vl( a r <br /> O.Z0,by F'r1'd LLIAdI/ as 1i. J4joriZed flprfSetri-0 r'✓{. of Gi‘nfn1,n C) 4fl)y <br /> CHRISTINE HOLLENBAUGH <br /> NOTARY PUBLIC <br /> STATE OF COLORADO Notary Public <br /> NOTARY ID 20184017122 <br /> MY COMMISSION EXPIRES APRIL 19.2022 �`� ��07 <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 />