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Certification: <br /> As an authorized representative of the applicant, 1 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)inexistence 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 34-32.5-1 15(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 Constriction 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 acid that false statements <br /> made herein are punishable as a Class t misdemeanor pursuant to Section 18-8-503,C.R.S. <br /> T his form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.R.S.,of the Colorado Land <br /> Reclamation Actfor the Extraction of Construction Materials. Any alteration or modification of this form shall rerult 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 permit pursuant to section 34-32.5-123,C.R.S. <br /> Signed and dated this day of <br /> c a �`-'k""C. <br /> 1f Corporation Attest( eall <br /> Applicant/Operator or Company Name <br /> Signed: Signed <br /> `` n C rpo ate Secrctar 7brquivalent <br /> Title: V 't'MCQVIA L 1l 'I'own/City/County Clerk <br /> State of _�d�� ra'� <br /> )Ss. <br /> County of ) t <br /> The foregoing instrument was acknowledged before me this G� day of 2°Z <br /> —,by C-! t t..xb - as J P PnL ;> n. of s e."t t' Tc. <br /> PAIWr-IA P{ARRINO t/tQ� (;��Mg <br /> NOTARY PU13UC Notary Public <br /> STATE OF COLORAOO <br /> NOTARY ID 20I040i5234 ! r} <br /> MY COMM4SStON EXPIRES MAY28,2024 My Commission expires: - U C <br /> SIG1NATU1R E;S 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 />