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-g- <br />.Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation describedhas rnet the minimum requirements of <br />the following teens and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made stmcture(s) in existence at the time this <br />application is filed, and located within 200 feet of the proposed affected area have ban identified in this application <br />(Section 34-32.5-1 IS(4)(e), C.RSJ. <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 applicanUoperator, I do not have any extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Rxlamation 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 made <br />herein are punishable as a Class l misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This jorm has been approved by the Mined Land Reclamation Board parsaam to secSan 3J-32.5-112,CRS, ojrhe Colorado Laxd <br />Reclamation Ad jor tke Extraction oJConstruction Materials. Any aherarYon or modification ojthis jorm akall resu@ in voiding any <br />permit issued on ffie altered o~ modifiedjorrr ondsub/ed the operafo~W ceose and desist order and civil penaE6esjor operatingxOhaat <br />a permit! parsaom to section 34-32.5-123, CRS. <br />Signed and dated this ~ day of 1_r, t~ sL <br />• ~P,-~FA-(ZCI c <br />ApplicanUOperator or Comparry Name <br />Sigrced: <br />Title: <br />Town/City/County Clerk <br />Sta[eof ~.0~(Q~D 1 <br />-__---)ss__ ,_- <br />The foregoing instrument was acknowledged before me this day of ~ ~. /.W~ <br />by ~Clll Srnl~h as ~'P ~flffCl~.l~ {{~ of~q~¢ Q V <br />r ''r- <br />~• 0 <br />C i ~, <br />ln~i+W o Y -ew=_ <br />~ob~ <br />If Corporation Attest (Seal) <br />Signed: - ~~~~/~"` <br />~'~ Corpora Secretary or Equivalent <br />~~ ~-d <br />Notary Public <br />My Commission expires: ' I ^ Q - ~~ <br />'~ ; Qa.j;; •••••"..'~ r`~ SIGNATURES MUST BE IN BLUE INK <br />• M:MinWaelwroem+\Cwevuctim II1 d« (Ayproved 05/11/LOOS) <br />