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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 know ledge,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 34-32.5-1 I 5(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 15(4)(t'),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 f_:rtraction 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. f <br /> Signed and dated this_ _` i� __ da% of /61/1./! _. ._...__..._• ---20?. ._• <br /> Rm <br /> S /NS (0a.)5fY✓c iaN Z-Z-L) If Corporation Attest(Seal) <br /> .Applicant.{}perator of Company Name <br /> A <br /> Signed tr ... ..f. Signed: — — — --- <br /> Corporate Secretary or Equivalent <br /> ,fNW <br /> "I itle: v At4r.Lve'K— Town,City.'County Clerk <br /> State of 6,4>Yet ' _- _) <br /> / I ss. <br /> County of tavo 5 a- ) <br /> lib- fbreguinu instrument was acknn ledged before me this _ _t(S","�,,_�day of. - 14"/�1//}}.210?"? • e 1 / <br /> b. '440.,a L. Qdb/rv3 as fa* of Kb b €2M- 7ttmlhty gyri-/ <br /> 73/( ------ <br /> WALTER STEVEN ROYBA. <br /> NOTARY PUBLIC Notars Public <br /> STATE OF COLORADO <br /> NOTARY ID E 201)403030 ) ��� <br /> MY COMMISSION EXPIRES JULY 19,2025 \ty Commission expires: / <br /> SIGNATURES MUST BE IN BI,UF: iNK <br /> v^., .—t �ost s iciest 'polices at the locatintit�l6ayelwszg x�e to clearly identify the site as the location of a <br /> NUMMI ngineering <br /> 44 719-589-6147 <br /> Alamosa, CO <br />