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-8- <br />Certification- <br />As an authorized representative of the applicant, I hereby certify thaz the operation described has met the minimum requiremems <br />of the following terms and conditions: <br />1. To the best of my lmowledge, 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(4xe), 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-i t5(4)(f), C.R.S.; <br />3. As the applicanUoperator, I do not have any extractionJexploration 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 />Th& farm has been approved by the Mined Land Reclamaion Board pursuant to section 34-32.5-712,CRS, of the Colorado Land <br />Reclamation AMJor the FauraMlon oj'Constrnctton Materials. Any aheration or modification of this form shall result in voiding any <br />permit issued on the ahered or modified form and sabject the operator to cease and desist orders and civU peaalNes jar operating <br />without a permit panuant to section 34-32.5-123, C.RS. <br />Signed and dated this ~ day of Pl~iia ~7P,r/ 2p©G~ <br />~d~N ~PSou.vr~~sr[vlr~. <br />ApplicanUOperator or Company Name <br />If Corporation Attest (Seal} <br />Signed• <br />'YV~/; <br />Title: ~, i ~~i~J~ <br />State of ~~~ 1 <br />/~~ ss. <br />County of /c•Pi~'- ) <br />The foregoing instrument was acimowledged before me this -_S.~- day of~ T 0 ~ o n ~ , <br />~p, by ~~hY'~~+1~- as Vr'rC~~C E'~2t~.~x~~ of Cahne~~e.50wOG2S ~~ <br />Notary Public <br />My Commission expires: <br />SIGNATURES MUST BF, [N BLUE [NK <br />M:HtinVharzlvsfmme~Lmuvuaion 112.da (Approved OS/I Il2005) <br />.„ <br /><v , <br />r` r ~ -. <br />t /.i - <br />~~~,. -,r , • _ yam' <br /> <br />