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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 minimumrequiremeuts of <br />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 this <br />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.RS.). <br />2. No mining operation will be located on lands where such operatians are prohihited by law <br />(Section 34-32.5-115(4)(f), C.RS.; <br />3. As the applicanUoperator, I do not have arty 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.RS.) as determined through a Boazd finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. <br />Thu form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.S-IIZ,CRS., ojthe Colorado Land <br />Reclamation Ad for the Extracton of Construction Materials. Any aperation or modifrcah'on of this form shall resuB in voiding any <br />permitissued on dre altered or modif+ed form and subjedthe operator to cease and desist orders and crvilpenalties for operat'vrgr~dhout <br />a permit pursuant to section 34-31.S-I23, GRS <br />Signed and dated this day of <br />ApplicanUOperator or Compaq Name <br />Signed: _ <br />Title: <br />State of _ <br />County of <br />ss. <br />The foregoing instnmrent was aclmowledged before me this <br />by <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/CiryfCounry Clerk <br />day of , <br />as <br />Notary Public <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />M1minl+harelvsromu\Cwstruction I12doc (Approved OS/1 moos) <br />