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-8- <br />Certification• <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements <br />of [he following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made stmcture(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 34-32.5-1 IS(4xe), 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(4xt), C.R.S.; <br />3. As the applicanUoperator, [ do not have any extractionlexplota6on operations in the State of Colorado currently in <br />violation of the provisions-of the Colorado Land Reclamation Act far the Extraction of Constmetion -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 are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Th&jorm has been approved by the Mined Land Reclammion Board pursuant to section 34-31.5-II2,C.RS, ojthe Colorado Land <br />Rec/amationActjortheExtractionojConstructionMaterials Any alteration ormodiJlcatlonojthisjormsha/lresultinvoidingany <br />permit issued on the altered or modified jorm and subjeM the operator to cease and desist orders and civll penaldes jor operating <br />without a permitputsuant to section 34-32.5-I23, QRS. _ _ <br />Signed and dated this 21~ day of ~ Ov'13~+..8t= 1Z2 7A0 ~ !' <br />:i <br />~~ ~Opt6.CCSi INc IfCotpora[ionAttest(soal_)-„ :, _~"• M1 - <br />ApplicandOpetator orCompany Name - = _ -r^` <br />Signed: Signed: <br />Cc <br />Title: t tsar+.T'f <br />or Equivalent <br />Towrv'City/County Clerk <br />State of 1 °,O LO.LA n r~ `-- 1-- ^- - -- - - <br />ss. <br />County of L~HAyt~t~ ) <br />1'he foregoing instrument was acknowledged before me this _ a 7 day of ~t/E'M/jt~,2 , <br />`,by. i~0[I/ DLlcElt/GFGC as PR£-stntar~rr of_~CA-P200r~LT5,T A/C~ <br />SHARON K. CARR <br />~_~~~~~ ~ ~~ c <br />NOTARY PUBLIC ~ NotaryPublic <br />STATE OF COLORADO / / <br />My Commission Expires 6/16/2007 My Commission expires: "' ~ <~ `~~ <br />SIGNATURES MUST $E IN BLUE INK <br />.N:~rnin;sMrewsfnrtre~Conewc,ion r1l.doc (Apprmed US/112005] <br />