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-8- <br />Certification: <br />REDEIVED <br />1AN 12 ~ <br />end Gea1o9Y <br />As an authorized representative of the applicant, I hereby certify that the operation describedhas metth>r'dt9P1@R19~requrrements of <br />the following terms and conditions: <br />I . To the best of my knowledge, all significant, valuable and permanent man-made swcture(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.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(C), C.R.S.; <br />3. As the applicanVoperator, 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 Extraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Board finding. <br />4. [understand that statements m the application are being made under penalty of perjury and that false s[a[ementsmade - -- _ - <br />herein are punishable as a Class 1 misdemeanor pursuant to Section i 8-8-503, C.R.S. <br />This jnrm has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.RS, ojthe Colorado Land <br />Reclamation AM jor the Extraction ojConstruction Moterials. Any aheratinn or modification ojthis jnrm shall resuh in voiding any <br />permit issued on the a0ered or modifiedjnrm and subject the operator to cease and desist orders and civil penaltiesjor operatingsvithout <br />a perm pursuant to section 34-31.5-113, C.R.S. <br />Signed and dated this ~ day of ~ `~ ~ ~bG ~ <br />ApplicanUOperat/or or Company Name <br />Signed: f ~ t~/b~r'- <br />Title: ~~ W ~-6 ~~~s~J~- ~""~- <br />Statcof ~Ut ~/ ~ ) <br />ss. <br />County of ~~~T l,(~ ) <br />TowrVCity/County Clerk <br />The forming insw~eat w eknowledged befo a this / 0 y ~ day of NCj ~ oav~s <br />by ~ // K .~dd~sv.J as cos"-~ or `ono o i~~~ >% <br />Y^' .~:r <br />- -^.: <br />~~~ ` ~ `L <br />^` `,^V <br />SHARON R. CLARK Notary Public <br />Notary Public. Bartow County, Georgia <br />Ahy Commissicn Expires July 20, 2008 <br />My Commission expires: ~~ a~~ <br />SIGNATURES MUST BE IN BLUE INK <br />[f Corporation Attest (Seal) <br />Signed: ~ ' <br />Corporate Secretary o Equivalent <br />A1:MinWUCWafwm~COmvua~on II2.dw (Approved 05/11/2005) <br />