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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 ofthe 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)(�, C.R.S.; <br />3. As the applicant/operator, ! 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 Boardpursuant to section 34-32.5-112,C.R.S., of'the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any a[teration or modification of this form shall result in voiding any <br />permit issued on the altered or modifred form and su6ject the operator to cease and desist orders and civil penalties for opernting <br />without a permit pursuant to section 34-32.5-123, C.R.S. � <br />Signed and dated this I�� day of <br />�} 1 h e��- �� � 5�:�.s� a`�-� � <br />Applicant/Operator or Company Name <br />�- <br />Signed: ��� -- <br />Title: PRESIDENT <br />State of �U � u �"c� c:1� �; ) <br />) ss. <br />County of � � Q �`^ ��'�'�-�� ) <br />.`�"` <br />r � I , ZG Z � ;�`,? � � � o ,�� ��,� . <br />�'�o , °_ -Adz t.� <br />' , ' � � ,. z � ..�q a 3� <br />y�'.� ;, <br />, �.. <br />If Corporation Attest (Seal) 'w' ` '' � -� f: <br />�. �,,, <br />�.�:,'`�"'„�" : <br />� <br />ti�„ <br />� <br />'r , �- /<' �-- <br />Signed: ��i <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this ���� day of /"� ,oY'� � , <br />20 Z I, by /� 1 C�'C_c ,�V' as PI--�g i C�e� � of �( he r l- G�r�� -1-- S�h Si �nL . <br />% � <br />REBECCA JO RIGO -�'- CC C -�` � <br />NOTARY PUBLIC Notary Public, <br />STATE OF COLORADO <br />NOTARY ID 20154038090 <br />MY COMMISSION EXPiRES 10I0212023 My Commission expires: l O Q Z 2 a z 3 <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 />