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-8- <br />'ficati n: <br />As an authorized representative of the applicant, I hereby certify that the operation describedhas tneitheminimumrequiremearts of <br />the following terms end conditions; <br />1. To the best of my knowledge, all significant, valuable and permaacntman-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 />(Seetion 34-32.5-115(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operetioos are probihited by law <br />(Section 34-32.5-1'15(4xf), C,RS.; <br />3. As the applicant/operator, I do not have arty extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for ffie Extraction of Construction Materials <br />(Section 34-32.5-120, C.RS.) as determined through a Board finding. <br />4. I understandthat statements iathe application are being madeunder peoslty of perjury anti thatfalse statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. <br />77ris form has been approved by the Muxed La»d Reclamation Board pursuant to section 34-3bs-IIZ,CRR, ojdrt Colorado Land <br />Reclmnatio» AcY for the Extraction of Construction Materials. Any attoatian or modifumtio» of 1RL form ahaR result in voiding any <br />permit iuued on dre altered or modijiedjorm and subleetthe operator m cease and duisrordtra and erviipenaUies for operat'vegxdhout <br />a permit pursumd to section 3¢31.5-I13, GRS <br />and dated this day of <br />Applicant/Operator or Cortrpany Name <br />Signed: <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary m Equivalent <br />Title: TowalCitylCauntyClark <br />State of ) <br />ss. <br />County of ) <br />The foregoing instrument was aclmowledged before me this day of <br />by as of <br />Notary Public <br />• My Commission expires: <br />SIGNA'T'URES MUST BE IN BLUE INK <br />ns:v~wwc~~r«m,s~ r Inez taapmroe osnrnoosl <br />