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_g. <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimtan regturanatLg of <br />the following terms and conditions: <br />1. To the best of my Imov+ledge, all significant, valuable and pdrnan~t man-made structure(s) in existence at the time this <br />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 l5(4)(e), C.RS.). <br />2. No mining trperaticn wHl be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), C.RS.; <br />3. As the appliranUopdator, I do not have arty extraction/exploration operations in the State of Colorado cmrrerrtly 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.RSJ as determined through a Board Ending. <br />4. [ understand that staterents in the application are being made order penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approsrd 6y the Mined land Reclamation Boord pwsaaru to section 34-32S-Il2,GRS, ojthe Co%ado Lm+d <br />Reclamatim~ Ad jor tire Extraction ojCanstrudion Materials. Any aUeration or modification ojthis jarm shall result in aoiding any <br />permit issued on the adtned or modifiedjorm and sabprd tke operator to cease and desist orders aad crvil penalticcjor operating»~kout <br />a permit pnrsaant to saxion 3¢32.5-123, CR.S. <br />Signed and dated this ~ day of 2D~ 7 <br />Applicam/Operator ~ Comparry Name <br />Sigmed: ~ C~- <br />Tide: _J~'77X~-~rC11v1 ~f~~/~C~Gi~- <br />State of CvI~~.~.dr, ) <br />ss. <br />County of r~~..{r_Z.. c;, ) <br />If Corporation Attest <br />Signed: <br />Corporate secretary or rym;valent <br />Tow-r/City/County Clerk <br />The foregoing instrumart was acknowledged beforepme this 2 S ~ day of <br />by K~ 6~~c as r1/`c.~aar,~ of <br />„~..~. <br />,~~°~~ ~ v <br />, c.; ,- <br />Notary Public %'~' <br />,~ <br />.;~ <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />~I <br />M:~minWaewsfmm~cmmuctian ~ ~2.doc (/~PPmved Os/11na05) <br />