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_~_ <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 ofthe 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 opemtions are prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicanUoperator, I do not have any extraction/exploration operations in the State ofColorado 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. t 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 jorm has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-I72,C.R.S, ojthe Colorado Land <br />Reclamation Act jor the Extraction ojConstruetion Materials. Any aheration or modification ojthis jorm shall result in voiding any <br />permit issued on the altered ar modifeed jorm and subject the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant to section 34-32-123, C.R.S. <br />Signed and dated this .~~ day of _ ~y~ ~a <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: ~'1W ~ C/L <br />State of <br />Town/City/County Clerk <br />ss. <br />Couniy of i / <br />The foregoi~ rostrum it /w/as- acknowledged before me this ~ day of ~Ccnl~/~/' a00 y <br />N by ~ puce( ~ muungi o OG~/' i c hk u-~ <br />----~......., yvii <br />tZOTARy'• <br />_ -~"o- <br />~,,..j°~BL10;~ ; Notary Public <br />My Commission expires: 3 C9 ' OS• <br />SIGNATURES MUST-@~ ~N BLUE INK <br />M:\min\vharc\vsfo,ms\Covstructivo 112doc (07282IX14) <br />