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7 <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)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)(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 Boardpursuant to section 34-32.5-112,C.RS.,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 mod fled form and subject the operator to cease and desist orders and civil penalties for operating <br /> without a permitpursuant to section 34-32.5-123, C//RS. <br /> Signed and dated this day of A� o J e'v►,b e 2 2021 <br /> UAL T�F <br /> Asphalt Specialties Co., Inc. If Corporation Atte ) �� <br /> Applicant/Operator or Company Name <br /> 4, CORPORATE <br /> S <br /> Signed: Signed: <br /> Daniel W.Hunt Corpo N)cjor Equ' VenTitle: President T <br /> State of Colorado ) <br /> ss. <br /> County of Adams ) <br /> The foregoing instrument was acknowledged before me this day of 1116 v P M�e R <br /> 2021,by Daniel W.Hunt as President of Asphalt Specialties Co.,Inc. <br /> JA'I M-7,' '94NI <br /> NO J I, <br /> STATE ' ADO No Public <br /> NO7AN 527 <br /> My Commission LAN. 129.2024 My Commission expires: 0 <br /> JANI NELSON <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19994030527 <br /> My Commission Expires April 29.2024 <br />