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-8- <br />CertiRcation: <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimumrequirements <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-] 15(4)(e), C.R.S.}. <br />2. No mining operation will be located on lands where such operations are prohibited by !aw <br />(Section 34-32.5-1 l5(4)(f}, C.R.S.; <br />3. As the applicanUoperator, I donor have any extractionlexptoralion operations in the State afColorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the F,xtraction of Constmc[ion 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 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 pursuant to section 34-32.5-111,C.R5., ojthe Colorado Land <br />Reclamation Act for the F,xtraction of Construction Materials. Axy alteration ar modification ofthisform shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civll penahles jar operating <br />wi[hou[ a permit pursuant to section 34-32.5-123, C.RS.?~/~ ~~'~ <br />Signed and dated this ~ day of ------.'i-f=" - '~-. <br />/I l Cl~ ~wrt <br />ApplicandOperator or Company Name <br />Sigtted: <br />Title: ~/i1~C <br />If Corporation Attest (Seal) <br />Signed: <br />Town/CiiytCounty Clerk <br />State of ~d/rG~L(/~ ) <br />~'/lk ~ ) ss. <br />County of __ _ ~ ) <br />The foregoin~* ins/trume t w acknowledged before me this !r ~ day of <br />_.by-- ,,,~.C uA~ _as~.fS~ ,lA~_ <br />Corporate Secretary or Equivalent <br /> <br />d-' d y Public <br />;~31_tG <br />~_° e. ,. <br />expires: ~~~~ <br />SIGNATURES bilJS"Ii~BE; N'= , ,INK <br />N'a,~in~stwrchsronnq~(:enainction 111.doc (Approved O$/I VZG1t) <br />