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certification: <br /> As an authorized representative of the applicant, i hereby certify that the operation described has met the minimum <br /> requiremcnis of the fallowing terms and conditions: <br /> 1. To the best of my knowledge,all significant,valuable and permanent man-made structure(s)inexistence 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 34-32.5-1 15(4)(f),C.R.S.; <br /> 3. As the applicant/operator,i do not have any e xtractioniex p lo ration operations in the State of Colorado currentiy 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 fake statements <br /> made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503.C.R.S. <br /> Thu farm has been approved by the Mined Land Reclamation Board pursuant to section 34 3L i-1/2,CR.S,of the Colorado Land <br /> Reclamation Act for lite Extraction of Construction aaierials. Ant•alteration or modification of this form shall result in vaiding any <br /> permit issued on die altered or modified form and subject the operator to cease and desist urders and civil penalties for operating <br /> widruttt a permit pursuant to section 34-31 S-123. C.R.S. <br /> Signed and dated this day of <br /> If Corporation Attest(Sea]) <br /> Applicant.Operator or Company Name <br /> Signed v� Signed: <br /> Corporate Secretary or Fquivalent <br /> itie: _ Town/City/County Clerk <br /> State ot <br /> ss. <br /> County of 1 <br /> i h,• fure_vUw it{%lrnr,vnt ►%as a,*kno%%ledged before me this <br /> day of <br /> bt <br /> cif <br /> Notary Public <br /> My Commission expires: <br /> SIGNATURES MUST BE IN BLUE iNK <br /> ' VWA � lcird eca <br /> lt Notices at the lti <br /> Nummt�' ngineering 9��fN to clearly identity the site as the 'cation of a <br /> 719-5894147 <br /> Mamma,CO <br />