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-8- <br /> Certification: <br /> As an authorized representative of the applicant, i hereby eertiCy 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 tiled,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 34-32.5-1 l5(4)(f),C.R.S.; <br /> 3. As the applicantloperator,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 /> oracle herein are punishable as a Class l misdemeanor pursuant to Section 18-8-503,C.R.S. <br /> Vtis f orm has been approved by the Mined Land Reclamation Board pursuant to section 34-32.S_112,C.R.S.,of the Colorado Land <br /> Reclamation Act far the Extraction of Construction Materials, Any alteration or modification of this form shall result in voiding any <br /> permit issued on the altered or modijied forth 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 3 GOtr <br /> -2�L Scott <br /> .�--. (el0 <br /> C_' if Corporation Attest( v f+� <br /> Applicant/Operator or Company Named�L <br /> Sighed: 05 Signed ` p` <br /> l C rpo ate Sceretar} os� r ..quivalent <br /> Title: V �M Cdv1`b�jY11c_ ✓ e <br /> Town/City/County Cleric <br /> State of Cd�3 f`'J 6 <br /> }ss. <br /> County of A "� } <br /> � 3 <br /> The foregoing instrument was acknowledged before me this day of LA 7°?, <br /> by C-!. [ t*kd as J P <br /> PAVUetA PAM CO <br /> NOTARY PUTS Notary Public <br /> STATE OF COLORADO <br /> NOTARY ID 2PIRFS MAY <br /> 28 <br /> 34 <br /> MY COMMISSION EXPIRES MAY 28,2p24 My 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 />