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Certtflcation: <br />-8- <br />As an authorized representative ofthe applicant, I hereby cercify that the operation described has met the minimum requirements <br />of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent loan-made structure(s) in existence at the time <br />this applicatton is filed, and located within 200 feet of the proposed affected area have been identified in this appltcation <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-I 15(4)(f), C.R.S.; <br />3. As the applicantJoperator, 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 Rct For the Extraction of Construction Materials <br />(Section 34-32.5-12Q, C.R.S.) as determined through a Board finding. <br />4. f 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 />• <br />This form has been approved by the Mined Land Reclamation Roard pursuant to section 34-31.5-112,C.R.S., of the Colorado Lnnd <br />Rec/nmalimrActfortheFxlractionafConstructinnMnterinls. RoyalteradarormodiJlcattonof[hisformshallresrdtnrl~ordiugany <br />permit issued on the altered or modified farm and subject die operator to cease and desist nrdars and civil penalties for operating <br />rvithou! a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this 20th day of <br />Weld <br />Applicant/Operator or Company Name <br />Signed: <br />Title: /lI~PG/tT o7 /'kd~pr Ctfm/~ <br />State of C .Ot..o!?q,-fY~ ) <br />ss. <br />County of (r)~r.n ) <br />Town/City/County Clerk <br />T'he foregoing instrument was acknowledged before me this _c~1~7rt" day of_~Q1~~, <br />dt~~> by _~..Ps11--},C1S---~>'~m~Al_ as ~+ Rrcti-cl a n$ P,ti2i , r 1.u1~c- - of __~ ~z,~ ~i.r ly~r~ <br />r <br />otary Puhlic Q~ ~ <br />• <br />SIGNATURES IVIIJST BF [N BLUE INK <br />M:\min\vha,re\vofi,nm\Gmsinraion 111.doc (AppRrved 0$/11/2005) <br />My Commission <br />/'UBLtG <br />Mu Commisswn F.xnires May 15, 2010 <br />