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i <br /> i <br /> I <br /> -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 haveteen 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 j <br /> (Section 34-32.5-115(4)(f),C.R.S.; j <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 Laud Reclamation Board pursuant to section 34-32.5-114C.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 nodifred forin 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 /> IRU%, <br /> Signed and dated this 1Oth day of April <br /> Kelley Trucking Inc. If Cor rati nr'�C/1 �TE , <br /> Applicant/Operator or Company Name <br /> Signed: Signe <br /> Corporat ecretary or Equival <br /> Title: ��`( //LG`rIO�N� Town/City/County Clerk <br /> State of Colorado ) <br /> )ss. <br /> County of_Jefferson <br /> The foregoing itistrum nt was acknowledged before me this 1Oth day of April , 2020 <br /> by LA W '� as Ui e �/>�i�,!/an'f of Kelley Trucking Inc. <br /> ROXANNA D.SPRENGER <br /> NOTARY PUBLIC Not ry Public <br /> STATE OF COLORADO <br /> NOTARY ID 20194017508 DS �� 1 n�� <br /> MY COMMISSION EXPIRES 0511512023 My Commission expires:_ �-V <br /> SIGNATURES MUST BE IN BLUE INK <br />