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-~- <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, valuable and permanent man-made structure(s) in existence at the time <br />this 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.R.S.). <br />2. No mining operation will be located on lands where such operations aze prohibited by law (Section <br />34-32.5-115(4)(fj, C.R.S.; <br />3. As the applicanUoperator, I do not have any extractionlexploration 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 (Secfion <br />34-32.5-120, C.R.S.) as determined through a Board fmding. <br />4. I understand that statements in the application aze being made under penalty of perjury and that false statements <br />made herein aze punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Signed and dated this ~ day of ~~ ~~ ~ <br />/IC%J'I <br />ApplicanUOperator or Cor any Name <br />If Corporation Attest (Seal) <br />Title: O/ /tel./'-e~i <br />:~ <br />State of c0~or~r ~CJ ) <br />T ) ss <br />County of I rCi/N't /IVIt ) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was~apckn~o pwpl~e~dged before me this day of (/.tw a u C'1- Zo OZ, <br />by W ~] ~ (~1 dr... ~ r eCL as M~-.-tea P.~ of ~ct~r~ ~---`~~r LLB <br />tJY/~,~' <br />Notary Public <br />My Commission Expires <br />My Commission expues: &29-2005 <br />SIGNATURES MUST BE IN BLUE INK <br />M:IMIMBDCNIINFORMS~2823C012.APP ]0/1]/Ol <br />