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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 nlIiiiniiIi11 <br /> requirements of the following terms and conditions: <br /> 1. To the best of my knowledge,all significant,. <br /> y g , uficant,valuable and permanent man-made structure(s)m existence at the time I <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 /> i <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.; 1 <br /> I <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 detennined through a Board finding. <br /> 4. 1 understand that statements in the application are being made under penalty of perjury-and that false statements i <br /> made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503,C.R.S. <br /> 1 <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 Alaterirrls. And,alteration or modification ofthisforin shall result in voiding any <br /> permit issued on the altered or modifier!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 /> 1RUCk/ <br /> Signed and dated this 10th day of April <br /> Kelley Trucking Inc. If Cor rati n P �TE . <br /> Applicant/Operator or Company Name <br /> Signed: Signe . <br /> i <br /> Corporat ecretaiy or Equival <br /> Title: ��//rP".( WNT Town/City/County Clerk- <br /> State of Colorado ) <br /> )ss. <br /> County of Jefferson ) <br /> The foregoing instrum�gnj was acknowledged before me this ��10th day of April . 2020 <br /> as Vl� PMti!/an'� of_Kelley Trucking Inc. <br /> � o <br /> LROXANNA D.SPRENGEROTARY PUBLIC Not ry Public <br /> E OF COLORADO <br /> RY ID 20194017508OC t�IM2Z <br /> It381pN EXPIRES 05M512023 My Commission expires: : I <br /> SIGNATURES MUST BE IN BLUE INK <br />