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-8- <br />Certification: <br />As an authorized representative of [he applicant, I hereby cenify 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 man-made structure(s) inexistence at [he time <br />this application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32,5-1 15(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)(f1, C.R.S.; <br />3. As the appticant/operator, I do not have any extrac[ion/explota[ion operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the F,xtraction of Consttnction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Board finding. <br />4, I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein aze punishable as a Class 1 misdemeanor ptusuant to Section 18-8-503, C.R.S. <br />This jorm has been approved by the Mtned Land Reclamation Board pursuant to section 34-32.5-111,C.RS, oJthe Colorado Land <br />Reclamation Act for the F,xlraction aJConstructton Materials. Any akeratlan or modifrcation ojthis jorm shall resuk in voiding any <br />permit issued on the altered or medifred form end subjeM the operator to cease and desk! orders and civil penalties jar operating <br />wt~houe a permit pursuant to sec~ton 34-32.5-123, C.RS <br />Signed and dated this ~ day of L~%T~~~il'~ _, 2~~ <br />If Corporation Attest (Seal) <br />Applicant/Operator or Company N <br />Signed: <br />Title: ~•~anagPi f <br />-r <br />Towrv'City/County Clerk <br />Staieof~Rl4~ ) <br />r' ' )ss. <br />County of ~! l?A~so ) <br />1'he foregoing in trument w1as acknowledged before me this _- ~ day of ,~ r~V t~_~~. <br />°, by __ ~~~1__ ~l ~ _ as ~ Q. Yfo `. f_' --, <br />-~ n ~-- <br />Notary Public <br />My Commission expires: __`~~~!SCSl_ <br />SICNATLiRES M1iIIST BE tN BLi;E INK <br />Signed: <br />Corporate Secretary or Equivalent <br />N'nndslun^n-elamriConm~wlicn 111.JeM (ApprMxd 05111201)5) <br />