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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)(fl,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 Colarado 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.RS.,of the Colorado Land <br /> Reclamation Act for the Extraction ojConstruction Materials. Any alteration or modification ojthis form shall�esult in voiding any <br /> per»rit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties jor operating <br /> without a permit pursuant to section 34-32.5-123,C.R.S. <br /> Signed and dated this ' L�-day of ////�/�C�/S� �—f'� �. , <br /> /v a� 3 r c If Corporation Attest(Seal) <br /> Applicant/Operator r Company Name <br /> C � �'�_1�-�-� <br /> Signed• Signed: <br /> Co or Secretary or Equivalent <br /> Title:T/2��', Town/City/County Clerk <br /> State of <br /> )ss. <br /> County of ��i ) <br /> � <br /> r <br /> The foregoin instrument was acknowledged before me t ' day of , ,� <br /> ,by ` -�... as of o p <br /> �u�+�� --- � <br /> Nor�unr rwuc <br /> sU►�oF tolo�►oo ary P blic <br /> NOtARY ID 2003�0�094 <br /> MY COMMI N Q(PIRES.JAN Y 19 <br /> y Commission expires: � <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 />