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-8- <br />Certification <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements <br />of the following terms and conditions: <br />1. To the hest 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 of the proposed affected area have been identified in this application <br />(Section 34-32.5-] 15(4)(e), C.R.SJ. <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 extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Fxxtraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Boazd finding. <br />4. 1 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 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This jorm has been approved by the bfined Land Redamation Board pursuant ro section 34-32.5-772,C.R.S., ojJhe Colorado Land <br />Reclamation Act jor the F,xh'action ojConstruction Materia/s. Any alteration or modification of [his form shall resu/tin voiding any <br />permit issued on Jhe altered or modified farm and subject [he operator to cease and desist orders and civil penalties far operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this ~ ~ day of ~ UO <br />Richard <br />Signed: <br />Title: (hmar <br />If Corporation Attest (Seal) <br />Signed: <br />State of Colorado ) <br />ss. <br />County of Ph; t t ; n c ) <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />i-- <br />The foregoing instrument was acknowledged before me this -~~ day of _ PLC! ___ <br />,26'!1~7.hy__R;rha___rrl F~vrPaY _as nwnr~r _ Of_j~s3rraar Pit ~~~ <br />~i <br />Notary Public <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUF, INK <br />- / <br />,~ 'a <br />T~• ~ <br />+ f a' . <br />.+ , •: i. 7 <br />:r,= <br />~__\ <br />0 <br />M:bnimeharc\vs(omc`Cnaam¢aion 112J,~c (Approved 05!11/2fN15) <br />