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-8- <br />Certilication: <br />As an authorized representative ofthe applicant, l hereby certifythat 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) inexistence 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(4)(e}, C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-1 l5(4}(f), C.R.S.; <br />3. As the applicant/opcrator, I do not have any extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamafion Act for the Extraction of Consttvcrion Materials <br />(Section 34-32.5-]20, C.R.S.) 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 <br />made herein are punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.RS. <br />This jorm has been approved by the Mined Land Reclamation Board pursuant to .secitoa 34-32.5-112,C.R.3., ojfhe Colorado Land <br />Reclamation Act for the Extraction ajConstructiax Materials. Any aReradon or madificatlox of this form shall result in voiding any <br />permit issued on the altered or modified form and subJeM the operator to cease and Aesist orders and clvll penahles jor operating <br />without a permit putsaant to section 34-32.5-123, C.R.S. <br />+~ 2004- <br />Signed and dated this 8 - day of f~,QOS} , <br />tVor YMer.. Le(or.do ~' s~1w.~,.,. ~„~ If Corporation Attest (Seal) <br />Applicanr/Operator or Company Name <br />Signed: L;r~i._S~,~o1.-~ <br />Title: ~t~roTVtr~ <br />Signed: <br />C rate Secre or Equivalent <br />State of /~f~/~lt J~Q ) <br />ty r!v ~! ) ) <br />Coon of <br />rT,,h\e~foregoing ms rument was acknowl dged before me this ~~ day of _L <br />~ c.dL.t by _ _~2~~~ zCc~ as %//_4,%/JI,i~O~ - <br />Town/City/County Clerk <br />~'~ $REPlQA J, MtsFARLANE Notary public ~ ~~ <br />NOTARY PUBLIC -~! /-~~ ~~ <br />STATE OF COLORADO My Commission expires: <br />My Commission Expires 9126108 <br />SIGNAT(JRES b9L'ST BE IN BLUE fNK <br />Ndnen~siare~~nfimms~.Cunsvwfion 112.dce (Apprwcd OSil liNxlS) <br />