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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 34-32.5-112,0 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 /> RU Cif/4/ <br /> Signed and dated this 10th day of April S � ' - 0 <br /> R 2n <br /> Kelley Trucking Inc. If Cori, ,n��`A(�`ft 'ta �'TE <br /> Applicant/Operator or Company Name <br /> /// <br /> Signed: A Signe.. 4!:.,k!..� �A. <br /> �Z►f►/vim <br /> Corporat-`-ecretary or Equival- <br /> 41/ <br /> Title: ga ?MOON 7— Town/City/County Clerk <br /> State of Colorado ) <br /> ) ss. <br /> County of Jefferson ) <br /> The foregoing instrum n was acknowledged before me/this p 10th day of April , 2020 <br /> ,by 6%10'A if as Ito //PS'i e)en'' of Kelley Trucking Inc. <br /> ROXANNA D.SPRENGER WAT5fnillirfA" <br /> NOTARY PUBLIC Not ry Public <br /> STATE OF COLORADO <br /> NOTARYION 20194017508 <br /> P� 051 2023 055/155/�Z3 <br /> MY COMMISSION My Commission expires: <br /> SIGNATURES MUST BE IN BLUE INK <br />