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-S- <br />Certification: <br />As an authorized representative of [he applicant, I hereby certify that the operation described has met the minimum requirements of <br />the following terms and'conditions: <br />1. To the best of my knowledge, al I significant, valuable and pertnanentman-made structures} in existence a[ 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.R.SJ. <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.RS.; <br />3. As the applicant/operator, I do not have any extractionlexploration operations th 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 34-32.5-12Q, C.RS J as determined through a Board finding. <br />4. I understand that statements th the application aze 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.R.S. <br />This form has been approved by the Mined Land Reclamation Board parsuant to section 34-31.5-111,C.RS, ojthe Colorado Land <br />Reclamation Ad jor the Exhadion ojConstruc6on Materials. Any aherafian or modification ojthis form shall resu@ in voiding any <br />permit issued on the ahe~ed or modifudjorm and subject the operator to cease and delis[ orders and civ8penahies jor operadrgrs,tihmd <br />a permit pursuant to section 34-32.5-123, C RS r~ <br />S1iglned and dated this 2nd day of ~M~ <br />• W ~ !~ /C~LS <br />ApplicandOperatoro ComparryName <br />Signed: <br />Title: ~ q ` N-.L~it_ <br />State of ~`~u-eIJY~~i rX r') ) <br />7 ) ss. <br />County of (~fl~(~ ) <br />The for/e oing instrument was acknowledged <br />by .~I~(t-GLtGL~~~J a: <br />2007 <br />st($6~ <br />r ~drporat~Secretary or ~uival <br />~~JJ Town/City/County Clerk <br />day of / ~ a ~7 , <br />~~~r j ~L <br />pUBL1C. ' ' <br />No Public <br />~OF ~ My Commission espires: <br />My Commisswn ENpkbE 0?I1a12010 <br />SIGNATURES MUST BE IN BLUE INK <br />M:MinWueh9(wms'Comwtion t12.d« (Approved 05/71/2005) <br />• <br />