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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 minimum requirements <br />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-[ 15(4}(e}, C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicant/operator, I do not have any extractioniesploration 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 I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form /ras been approved by the Mined Land Reefmnation Board pursuant to section 34-31.5-112,GR.S., of the Colorado hand <br />Reclamation ~1ct for the Extraction of Construction Materials. Any alteration or modification ofthis form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to ceose and desist orders and civil penalties for operating <br />without a permit pursuant ro secHon 34-32.5-123, C.R.S. <br />Signed and dated this _~ day of << H'~"~(yjC'~ > ~ ' <br />~~ ~l-nw..,, ~o. (> If Corporation Attest (Seal) <br />Applican perator or Company Nam <br />Signed: Signe <br />_ A Corporate Secretary or F,quivalent <br />Title:____ K~Q~-._.~e~ ~ ~..o.,,,r- TowmrCity/County Clerk . <br />State of-~~~------} <br />~ // } ss. <br />Countyef (~pX(~C..__..----....._} /q <br />T'he forego--i~n~g~ rin~strument was acknowledged before m~~e ~th.,i"s ___ S-~/,-~ day of _ ,., -/~ _,, <br />-' by __~ ESL -~+ c~-- - as -QS-C3L%~!LZC~,S_LY~rt//lr Pr.--- °f ~~~~w r'~J_.._~~~~ - <br />5P S, Kqy~ ~~ _ <br />WQ~ Np7ARV ~ N tary Public <br />!- <br />tP o0 y Commission expires:.„_~ ~s-~2~ <br />9~ ~L`C ~~ <br />stcivA•rIi e~;rs~ra~%~a~'t~r: I ti IC <br />