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-8- <br />Certification: <br />As an authorized representative of the applicant, Ihereby certify that the operation described has met the minimurn 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) is 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(4xe), C.RS.). <br />2. No mining opeaation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-I15(4)(f), C.RS.; <br />3. As the applicsatlopcrator, I do not have any extraction/expioration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Ad for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.RS.) 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 made <br />herein are punishable as a Class 1 m;cAr,,,ranor pursuant to Sation 18-8-503, C.RS. <br />This form has beer approved by the 11fured Land Reclamation Board pwsumrt to scdron 34-32.5-I12,GRS., of tke Colorado Land <br />Reclmnatiox Actfor the Extraction of Construction Materials. Axy aNaation or modifrcation of this form shall resrelt ix voiding any <br />permit issued on the aboed or modJiedjorm and subject the operatorta cease and desist orders acrd civilpexa6Ser fog aperad'vrgwitfeout <br />a pamitpursuanf to section 3¢32.5-I23, C.RS <br />Signed and dated this ~ day of T ~. <br />Applican erator or Compaq Name <br />Signal: -'~ ~+~ <br />Title: ~~i~~r~~l/ ~/ <br />State of ~~~~~ ) <br />ss. <br />County of G, ~~~d ) <br />The foregoing inctmrnrnr was aclaowledged <br />by ~ w:l~.~ a uu ~ as <br />NOTAgy `. <br />`- ~'~'OC'gLIG ~~ = <br />;,~`, ~,. <br />~,.~n-•.-_. <br />Notary Public <br />My Commission expires: oc, i~a-I moo r <br />SIGNATURES MUST BE IN BLUE INK <br />If Corporation Attest'(;eal~__.__ ~ ~. <br />- .F <br />~~ <br />-,: <br />~ _: i~ [a" <br /> <br /> <br />Clerk <br />before me this ~ ~ "' day of ,~4w don s <br />S~~,reh. of ~ .~.,~..aa..,:. ~a~cwn ins, <br />M ~~~~~~ r ~aaa (Approvca osn moos) <br />