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8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operatron described has mei the minimum <br />requirements of the following terms and conditions: <br />t. To the best ofmy 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 of the proposed affected area have been identified in this application <br />(Section 3432.5-115(4)(e}, C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 3432.5-1 IS(4)(t), C.R.S.; <br />3. As the applicant/operator, I do no[ have any extractioNexplontion 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 aze being made under penalty of perjury and that false statements <br />made herein aze punishable as a Class 1 misdemeanor pursuant to Section 18-g-503, C.R.S. <br />This form has been approved by the Mined land Reclamation Boardpursuant to section 34-32.5-L12,C.R.S., ojthe Colorado Land <br />Reclamation Act jor the F.xtracrion ojConstruction Materials. Any Nteration or modiftcat5on ojthis jorm shall result in voiding any <br />permit issued an the a//ered or modified form and subject the operator fo cease and desist orders and civil penalties jor operoling <br />without a permit pursuant to section 34-325-123. L.R.S. <br />/~ ~- <br />Signed and dated this '~/ day of ~ ~ GC/1 e- ZUO S <br />~~ ~ ` - ~ i7t ' ,e ~ ~ /A!r ~a ~t ~~, ~ ~ ~~G if Corporation Attest (Seal) <br />ApplicantlOperator or Company Name ~ <br />Signe <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: <br />State of (a~o raaa ) <br />ss. <br />County of MOret a r1 ) <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me th' day of~ l GL Vl e- , <br />`Z~S,by t,a[mL5 ~. rVlinet~as ~lSi Qr'tf of 6 <br />GGrp •~1/ <br />'~4i ~~~~ ,~ o ublic <br />_ ` ^! '` _ MY ComoT~sionE~itt~ <br />~' "' ' My Commission expires: OB(ZiI2DD7 <br />IN BLUE INK <br />M:~minuAeiervsfaans'CaW~uaion 112.dnc IAOOroved 0511 <br />