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..; <br />-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation describedhas met the minimum requirements of <br />the following terms and conditions: <br />1. 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 34-32.5-115(4)(e), C.RS.). <br />2. No mining operation will 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 applicandoperator, I do not 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 Consauction Mazerials <br />(Section 34-32.5-120, C.RS J 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 made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section I5-8-503, C.RS. <br />This farm has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,GRS., ojihe Colorado Land <br />Reclamation Act jor the FaYradion ojConstrudion Materials. Any operation or modifuateon ojUtir jorm shall result in voiding any <br />permit issued on the altered or »todifiedjorm and subjed the operator to cease and desist orders and civilpenabfies joy operaBngwGliotd <br />a permit pursuant to section 34-32.5-I23, GRS. <br />Signed and dated this _~~ day of ` ~ ~5~.~~L. ,~_. <br />Applicant/ erator or Compaq Name <br />Signed: ~~~~.~ <br />Title: <br />State of . ~®~~ ~ <br />ss. <br />County of ~~ti~Q ,, o 1 <br />as ('~~ ~ ~ <br />The foregoing instrument was acknowledged before me this O(~ day of <br />by <br />If Corporation Attest (Seal) <br />Signed: <br />Notary <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />My Commission expires: C7 5~ b $ ~ ~ 00 ~p <br />~~GNATURES MUST BE IN BLUE INK <br />M~min~Snare~Krovn.~Canauction~~z.a« tapp~o~~a os~ttnoosl <br />