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~- <br />Certification: <br />As an authorized representative of the applicant, 1 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, al] significant, valuable and permanent man-made structure(s) inexistence atthe time <br />this application is filed, and located within 200 feet of the proposed affected azea have been identified in this application <br />(Section 34-32.5-115(4)(e), C.R.S.). <br />2. No mining operation will be located on lands where such operations aze prohibited by law <br />(Section 34-32.5-I15(4)(f), C.RS.; <br />3. As the applicanUoperator, I donot have any extraction/exploration operations in the State of Colorado currently 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 Boazd finding. <br />4. 1 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 I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamaton Board pursuant to section 34-31.5-711,0 R.S., ojthe Co[orndo Land <br />Reclamation Act for the Extraction ajConstruction Materials. Any alteration or modif:eation ojthisjorm shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-32-123, C.RS. <br />Cigned and dated this ~~ day of~?UD..C`Ul ~_3' Jl.l'f <br />Title: /~/G w` fl C~ ~o , <br />State of !~ <br />ss. <br />County of ) <br />The foregoing instrument was acknowledged be <br />by I ~~ ~lE'1~}'1C~lCp r _ as <br />0~'1 OT.4e ~~- . <br />• ~ Qj.: _ <br />~O- <br />~/'. ~~ , p~pp ~~' <br />~''+a,yy~;;,W;:~Coozm,onon i lz.doo (ovzsn_aoa~ <br />1 f Corporation Attest (Seal) <br />Signed: V <br />~(~~ <br />~u~uu,r <br />Corpora Secretary or Egyi•WA~e~t,~~'•.y,_ <br />Notary Public <br />My Commission expires: ~ qJ~ <br />SIGNATURES MUST BE IN BLUE INK <br />