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<br />g- <br />Certificstioo: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requuerrrarts of <br />the following terms artd conditions: <br />l . To the best of my knowledge, all significant, valuable and permanent men-made strucnrre(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 />(Secdan 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 34-32.5-1 IS(4xf), C.RS.; <br />3. As the applicanUoperator, I do not have arty extractioo%xploration 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 though a Board finding. <br />4. I understand that statements in the application are being made under penalty of prxjury and that false statemetts made <br />herein are punishable as a Class l misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Tbia form boa been approved by the Mined Land Reclamation Board paranarrt to atction 3432.5-Il2,GRS, ojtire Colorado Land <br />Reclamation Ad joy tire Fxhadio» ojConstradio» Materials. Any aberation or modification ojtbia jo~m aba(1 resab in voiding any <br />permitissaed on ffie a!lered or modifiedjorm and snbjed tine aperatw m cease and desist orderr and civil penaNies jar operafutgrWboat <br />a permit parsaam to aeation 34-32.5-123, GR.S. <br />Signed and dated this ~_ day of ~~6~ a ~~ 2 ~ <br />Kiowa County <br />ApplicanUgpera[or ~ Comparry Name <br />signed: <br />Title: Chairman <br />If Corporation Attest (Seal) <br />signed: C./ <br />Corporate Sec tary or Equivalent <br />Town/Ci County Clerk <br />State of COLORAI)D 1 <br />ss. <br />County of RIOAA 1 <br />The foregoing insinanent was acknowledged before me this 91 ct day of Fnhrna r ~nnt: , <br />~, Rodney Brown as Chairman of Riova County <br />Debra A. Immer, Notary Public -~~~'"" ~m~' <br />State of Colorado Notary Public <br />My Commission Expires ii/15/2009 <br />My Commission expires: November 15, 2009 <br />SIGNATURES MUST BE IN BLUE [NK <br />na:~ow~a~.,~corow~.a~ „x a~ rMProvea osn lnoos~ <br />