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7- <br />~:ertification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />1. To [he best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence at the time <br />this application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-I15(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.R.S.; <br />3. As the applicanUoperator, 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.) az determined through a Board finding. <br />4. ]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 I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Thu form has been approved by the Mined Land Reclmm~tion Board pursuant to sectiorr34-32.5-111,GR.S., ojthe Colorado Land <br />Rec/amrttion Actjor the Extraction ojConstruction Materials Any alteration or mod~cafion ojthis jorm shall result in voiding any <br />permit issued on the altered ar modified jorm nrsd subject the operator to cease and desist orders and civil penalfies jor opernting <br />without a permit pursuant to s¢ctian 34-3LI23, GRS. <br />Signed and dated this_~ day of ~ ~)~.~P/~K ~~ Y , ~~ <br />Title: /~/G w~_ ~} (v (o , <br />State of O.f l~ <br />) SS. <br />County of ) <br />If Corporation Attest (Seal) <br />Signed: (G~/c' <br />,•n44Y„• <br />f •- Corpora Secretary or Eq~r~rtpt~..,~ <br />:y <br />kt: <br />~ <br />Ot4 <br /> <br /> <br />yti~~.+~: <br />The foregoin instrument was acknowledged before me this day of I It)u{° t^J1G~i' C r l~tJ~I`I +"•""""~••", <br />by...l [X~t~ ~:('})'{ICJ~.I~ az Et L~Q ' l' 't of ~f'~ ~(~Q I 1 ~. TI {`X`.• <br />J /~ ~ ~ J <br />0~' •••,••..•- • - I Notary Public <br />r t~0 T.q 4 - <br />t' A ~ ~ J -: My Commission expires: <br />• ~r ^••••~~P~•~r SIGNATURES MUST BE IN BLUE INK <br />r1~~~~sK'w:n„rria, ~~z.a~ toraarzooor <br />