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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 I 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 f.� day of _.,/r,t ` 20?V <br /> If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> L4Signed: L.�. C Signed: <br /> Corporate Secretary or Equivalent <br /> Title: t`i(.i tAre-° ' Town/City/County Clerk <br /> State of Colr-v ) <br /> )ss. <br /> County of J a cks n ) <br /> The foregoing instrument was acknowledged before me this i fj day of itAk <br /> 212_2_1 by 44llrc(3 Cne-k e <br /> as Owner of #8n) Corkle Ccosirt.+ch an <br /> titAAJ-(3eifrAAAAJ <br /> Shannon L 8ad�,7c;?reene <br /> sT1':OF v0-1.-%F!ario Notary Public <br /> h1C rAFef!t� V2 t400.783 <br /> MY COWPSS.v: f,XmIRES February 12,2025 <br /> ------ My Commission expires: fiel) (a 21)?..S <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 />