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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)inexistence 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 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 /> Signed and dated this l a day ofl'z�-su <br /> owa- Cot>-nJU Ro 1� �dcc�� If Corporation Attest(Seal) 4 . <br /> Applicant/Operator or Co any Name '''' <br /> ' ^A� <br /> �1 •t <br /> Signed: 4.d gaelne Signed: r <br /> CW <br /> " r2 <br /> Corporate Secretary`/ , gtAval&t "' = <br /> Title: Chairman, Kiowa County Road & Bridge Town/City/ ) ty Clerk* <br /> State of 01 o ra d� ) <br /> )ss. <br /> County of � 11jc--. ) <br /> The foregoing instrument was acknowledged before me this 1 a day of N)0 V-eM ejc , <br /> 1 " <br /> by 17c).y1 cici �L,U c6 c� as Chl ,t.l'►—✓Yl�� of jn� ��� r`�D. ud e— <br /> DEBORAH ANN DERBY Nota <br /> NOTARY PUBLIC Notary Public <br /> STATE OF coloRADo <br /> NOTARY ID#20154006880 My Commission expires: <br /> MY COMMISSION EXPIRES 2/100 <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 />