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7- <br />CertiFication: <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 the best of my knowledge, all significant, valuab]e and permanent man-made structure(s) in existence at the time <br />this application is filed, and located within 200 fee[ of [he proposed affected area have been identified in this application <br />(Section 34-32.5-] 15(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-I l5(4)(f), C R.S.; <br />3. As the apphcant/opera[or, I do not have any extrac[ion/explora[ion operations in the Slate of Colorado cunen[ly 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 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 ptusuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Raard pursuant to section 34-32.5-I11,C.R.S., ojthe Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification ojthisform shalt resutl in voiding any <br />permit issued on the altered or modified jorm and subject the operator to cease and desist orders and civil penalties jot operating <br />without a permit pursuant to section 34-31-123, C.R.,S./~ / <br />Signed and dated this ~ day of ///.ts2~d1~6~/'~ , ~. <br />King Mountain Gravel, LLC <br />Applicant/Operator or pan ame <br />Signed r <br />Title, ~~.~sd/.~ <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of ~I[ tL"L~J O 1 <br />ss. <br />County of ,~2-~'~2(-SO1~ ) <br />The foregoing instrument was acknowledged before me this <br />,by Ktrk T. Ebert as Mer <br />h day of /l/t <br />'r^ ~ <br />_____~~ <br />Notary PubLc"::ic <br />My Commissio expires• „~- ~.'~-~h <br />M ~nmsshoreWSfortns`Cuwsrtuchw 1 @ Ea (0~rz8¢OOa) <br />BLUE INK <br />