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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of <br />the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence at the time this <br />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.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.RS.; <br />3. As the applicant/operator, I do not have arty extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Constmction Materials <br />(Section 34-32.5-120, C.RSJ as determined though a Board finding. <br />4. [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 1 misdemeanorpursuant to Section i8-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-II2,C RS., ojthe Colorado Land <br />Reclamation Ad jar the Extraction ojConstruc7ion Materials. Any alteration or modification ojthis form shag result in voiding any <br />permit issued on the akered or modifiedjorm and subject the operator to cease and desist orders and civil peno!lieforoyenAingnifhout <br />a permit pursuant to section 3J-31.5-123, C.RS. <br />Signed and dated this J~ S+ day of "t11 l,~i`lC ~ . ~-d~ _~c,`,=!'"-~---, _ . ,~ <br />Albert Frei and Sons, Inc. ^. - ~ ~~. s <br />O If Corporation Attest (Sc~aJ)'-_.. ~ ,. <br />ApplicandOpemtor or Com arty Name "%., ~ ,~' = r, ,~ ; <br />Signed: Signed: ~~~ <br />Corporate Secretary or Equivalent <br />Title: President p Town/City/County Clerk <br />State of Colorado <br />Adams ) ss. <br />County of p <br />The foregoing instrument was acknowledged before me this _~~ day of"~`1~Q~~f%t^- D O <br />by Albert R. Frei o as President ~ of Albert Frei and Sons, Inc.n ~ _o <br />`9`^~~ <br />tart' Public <br />My Commission expires: 0 <br />SIGNATURES MUST BE IN BLUE INK DOREENA G. ARKS <br />Miminhfiue\vsfomu\Consvudim 112.doc (AVaroved osn tnoos> NOTARY PUBLIC <br />STATE OF COLORADO <br />MY Commission Expires 1112012009 <br />