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- 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 la«- <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.R.S. <br /> This 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.act for the Extraction of Construction Materials. Any alteration or modification of this form shall result ill voiding any <br /> permit issued on the altered or modified forin and subject the operator to cease and desist orders and civil penalties_/or•operating <br /> ivithout a permit pursuant to section 34-32.5-123, C.R.S.Signed and dated this Pr — �G day of Gr1I sQge <br /> WwAyy-Pe► Or6aK: o Alark V,.b'K(,6 If Corporation Attest (Seal) <br /> Appiicant/Operator or Company Name <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Titie:QW rwe Town/City/County Clerk <br /> State of CCDb('GiA ) <br /> ss. <br /> County ofrCJ�( �1 ) <br /> The foreQoin(y instrument was acknowledged before me this � da of <br /> y <br /> a2L_, by as of <br /> (:]L IUD— <br /> e�--- <br /> PAMELA M BACON r <br /> Nota Public <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19934018610 <br /> MY COMMISSION EXPIRESDECEMBER?,20?S 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 />