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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 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 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 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 t'a day of f"Vj, <br /> _ _ _ _1k • �_ .�� . .. t C If Corporation Attest(Seal) <br /> Applicant/Operator or Company .me <br /> /� ,tNh/gi11111N/j•• <br /> Signed: �►�'(%4C 0 dip �'•:, Signed: <br /> :4tr .• p 0 R, TF t Corporate Secretary or Equibalent <br /> Title: ,' ~ x °SEAL o = Town/City/County Clerk <br /> : •• <br /> 1976 . �,o <br /> State of ) s�7 Cot• oRP.y•'2� a; <br /> County of ) )S ,''•`O • <br /> NN4u X1/1, ,, ` <br /> The foregoing instrument was acknowledged before me this ZG day of <br /> Z-1,by 142..c1 C./Dv-A. 1 as ..5:,CAD r\tt of <br /> Cor ' I,nG <br /> CAITLYN KAUFFMAN <br /> NOTARY PUBLIC Notary cirlic <br /> doz <br /> STATE OF COLORADO <br /> NOTARY ID 20184035097 My Commission expires: 9/'- . Z,Co <br /> MY COMMISSION EXPIRES SEPTEMBER 04,2026 <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 />