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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 requirements of the <br />following terms and conditions: <br />1. This mining operation will not adversely affect the stability of any significant, valuable and permanent man-made <br />structure(s) located within two hundred (200) feet of the affected lands. (However, where there is an agreement between the <br />applicant/operator and the persons having an interest in the structure that damage to the structure is to be compensated for by <br />the applicant/operator (Section 34-32-115(4)(d), C.R.S. 1984, as amended), then mining may occur within 200 feet. Proof of <br />an agreement must be submitted to the Office prior to the decision date.) <br />2. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32-115(4)(f), <br />C.R.S. 1984, as amended); <br />3. As the applicant/operator, I do not have any mining/prospecting operations in this state of Colorado currently in <br />violation of the provisions of the Mined Land Reclamation Act (Section 34-32-120, C.R.S. 1984, as amended) as determined <br />through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S 1984, as amended. <br />This form has been approved by the Mined Land Reclamation Boardpursuant to section 34-32-112,C.R.S., of the Mined Land <br />Reclamation Act. Any alteration or modification of this form shall result in voiding any permit issued on the altered or modified <br />form and subject the operator to cease and desist orders and civil penalties for operating without a permit pursuant to <br />section 34-32-123, C.R.S. ,n <br />Signed and dated this +� day of elm' Q <br />k <br />Fremont Paving & R!R-Mix, Inc If Corporation Attest (Seal) '' Ti! " <br />p I I il,, , : c <br />3hnv Name <br />Signed: <br />Title: <br />4�J�f -A AJ- <br />State of .,� 1y ►- ) <br />ss. <br />County of gi17u] <br />0 , <br />.1 <br />Signed: <br />Corporate Secretary or Eq 'vaj t 1. L <br />Town/City/County CNrk <br />The foregoing instrument was acknowledged before me this / 1I& day of _ <br />1' by ]� A P as XUtAl of <br />Oay o <br />Ax/ <br />11 <br />v <br />My Commission expires: v <br />SIGNATURES MUST BE IN BLUE INK <br />JODI D SCHREIBER <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 20064001792 <br />COMMISSION EXPIRES OCTOBER 6. 2022 <br />