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<br />Certification. <br />Signed: <br />-~- <br />Division of Mine. 3 , ~., nln;. <br />As an authorized rcpresenta[ive oC the applicant, [hereby certifi• that the operation described has met the mrnlmum requirements <br />of the following terms and conditions: <br />I. To the best of my knowledge, all significant, valuable and permanent 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.E-1 I~(4)(e), C.R.S.}. <br />2. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-1 li(4)(F), <br />CRS.; <br />3. As the applicandoperator, I do not have any extraction/exploration operations in the State oC Colorado currently in <br />violation of the provisions oC the Colorado Land Reclamation Act for the Extraction of Conswction ivfaterials (Section <br />34-32.~-120, C.RS.) as determined through a Boazd fording. <br />4. 1 understand that statements in the application are being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-~03, C.IZS. <br />Signed and dated this .~_ day of <br />Applicant/Operator or Company Name <br />Signed: <br />Title: O Pt<~ATo~ <br />State of CO Lo ~~ lit) ) <br />ss <br />County of A~LfI/Y/OS~ ) <br />The foregoing instrument was acknowledged <br />by ~N 1 EL /~'/ Ry4 Ff ~L as <br />~CIEIVED <br />~u~ 3 t 2nm <br />If Corporation Attest (Seal) <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />for ~;' = ' ~ day of ~~ , 'L~~ , <br />~•.• <br />' ~, of ~l~N c /Ji ~r <br />:.~ •~ ,,; <br />", ,_ <br />1c „~' ,G, ~-~ ~~ <br />' = ~~ ,C <br />" ;•." .. `-'~ ~j/~, otary Public <br />`,... •; <br />\~~;:: ~~ <br />D 2 zoo <br />My CommissionEspires10125120~3 My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />M:'mia'sbueWtCmve`2121C012APP (D7/I7R000) <br />