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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 5 day of 5C,0k 1 , 202.Li . <br /> —Dolores Co u n R o cLc ,1 o f It � If Corporation Attest(Seal) <br /> Applicant/Operator or Compan Name <br /> r <br /> Signed:5 Lltu•—. Signed: <br /> Corporate Secretary or Equivalent <br /> • <br /> Title: ( 1.1Yr+u ROQILA el'V(S 0 1' Town/City/County Clerk <br /> State of 0,bA0ro '- ) <br /> )ss. <br /> County of 7pl0,reS ) <br /> The foregoing instrument was acknowledged before me this S day of , <br /> 4,by 5k-?i.,e ->Q.V-tS as R oa.s yvi it of 17l or0 S COLU <br /> SHAYLA OLIVER1 L.i.:i <br /> . <br /> NOTARY PUBLIC Notary 1'ubl <br /> STATE OF COLORADO <br /> NOTARY ID 20224039041 <br /> MY COMM..;ION rXP!RES OCTOBER 7,2026 <br /> -•----- My Commission expires: air 1 , 21:219 <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 />