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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 fording. <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 Boardpursuant 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 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 34-3Z5-123,C.R.& <br /> r� <br /> Signed and dated this_ _day of ce- �✓l � 1 c U�- 1. <br /> r <br /> L Cq , L I If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> Signed: Signed: �z <br /> Corporate S cretary or Equivalent <br /> Title: 1-e•s cLIA.� Town/City/County Clerk <br /> State of U r U ) <br /> ss. ' <br /> County of �'J (f ( G ) <br /> r ct <br /> The foregoing instrument was acknowledged before me this 3 day of F2 rvt CA f-,- 1. , <br /> l ,by e,rrf 0'1; tC-e- as r�S �`e��'�� of 4 OL gr (d <br /> SHELLEY R KING <br /> NOTARY PUBLIC <br /> STATE OF COLORADO Notary Public - <br /> NOTARY ID 20124055547 <br /> MY COMMISSION EXPIRES AUGUST 29,2024 My Commission expires: S c, <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 />