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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. 1 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.K 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 of Construction Materials. Any alteration or modification of thisform shall result in voiding any <br /> permit issued on the altered or modified 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—17-.2'-J day of 416 J&_w.bga_ 2021 <br /> SQEC�►t.Tj� <br /> Asphalt Specialties Co.,Inc. <br /> If Corporation Atte ) <br /> Applicant/Operator or Company Name <br /> ���_ s <br /> Signed: Signed: <br /> Daniel W.Hunt <br /> Corporat or Eq ' en <br /> Title: President To erk <br /> State of Colorado ) <br /> )ss. - <br /> County of Adams ) <br /> The foregoing instrument was acknowledged before me this —day of Al6 v P nh I?P R <br /> 2021,by Daniel W.Hunt as President of Asphalt Specialties Co.,Inc. <br /> JAN NELSON <br /> NO LIC <br /> STA-�i g�� No Public <br /> NOTAR 527 <br /> My Commission LAp. •1 29.2024 My Commission expires: <br /> JAN NELSON <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19994030527 <br /> My Commission Expires April 29,2024 <br />