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- 8- <br /> Certification: <br /> As an authorized representarive 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 /> (5ection 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 Colorado Land Reclamarion 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 secdon 34-32.5-112,C.RS.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or inodiftcation of this form shall result in voiding any <br /> permit issued on the altered or ntodifted 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��day of ��'N� - ,��G''� U " <br /> �G��f � �'�.5 , CC=/�� � - If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> � <br /> Signed: ��� n-x-ti'G✓ Signed: � � ' S5�%U-�,� <br /> Corporate Secretary or Equivalent <br /> Title:��eS ��C' l/1- � • Town/City/County Clerk <br /> State of V"�r�"�`"� ) <br /> /��f�' �I " )ss. <br /> County of / '�( 1.�'`�'' ) <br /> /�,� , <br /> The fore ' 'nstnxment was a wledged before m thi � day of�Q��''"""' � <br /> GV� ,b_y 1(����• r�as 1� �/ . <br /> STACY L RAZ2AN0 ' v <br /> Not�ry Public—5tate of Colorado <br /> Notary ID 19934000126 Ot21y PUb11C - <br /> My Cemmissipn Expires Jan 29,2021 <br /> My Commission expires: � � �-�1 <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 />