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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,CRS,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, CR.S. <br /> Signed and dated this day of C1Yti\j .,k. , QM.Lt . <br /> Com(3 c1`� If Corporation Attest(Seal) <br /> Applicant/ r or Company Name <br /> • <br /> Signed: 'cl) CORPORATE ' y�--.Signed: �c Ea u a� -va�r/ta <br /> w FRICO = Corporate Secretary or Equivalent <br /> Title: Q t.A,( . `�V�f; j,,fac .- � , SEAL :; �: Town/City/County Clerk <br /> NY�y1.... Nd.� � <br /> State of LC 10 (7 ) <br /> )ss. <br /> County of Pvet(XJ s ) <br /> The foregoing instrument was acknowledged before me this _5 day of /vote,, -r <br /> aD 4,by 5L'o{t eri as C/.tehe fair 4 { oraftWI.�te-vV06(d-Trr►,a$a <br /> �l i �ux. f <br /> `. :.wt� <br /> \c jt-L( ilF1 <br /> MOLLY LOCKHART Notary Public <br /> NOTARY PUBLIC ►NL t <br /> STATE IDF C2 0440136 Myexpires: I ' Ut1 ��l dO <br /> NOTARY ID 20044013601 Commission l MY COMMISSION EXPIRES MAY 6,2028 l <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 />