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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of <br />the following terms and wnditions: <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 aze prohibited by law <br />(Section 34-32.5-1 li(4)(f), C.RS.; <br />3. As the applicant/operator, 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 Construction Materials <br />(Section 34-32.5-120, C.RS J as determined through a Board finding. <br />4. I understand that statements in the application aze being made under penalty of perjury and that false statements made <br />herein aze punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. <br />This form has been approved by ike Mined Land Reclamation Board pursuant to section 34-32.S-II1,C.RS., of the Colorado Land <br />Reclamation Act jor the Extraction ojConstrudion Materials. Any aperation or modifualion of this farm shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease wnd desistorders and civil penaHies for operatingwithout <br />a permit pursuant to section 34-31.5-113, GRS. <br />Signed and dated this 22~d day of ~t <br />~{'IA [L-vIIYLI~QE'fiP~i ~D ~ ~ IKI <br />ApplicandOperator or Company Name <br />If Corporation <br />~PORATE <br />:SEAL. <br />Signed?S~~\ <br />Title: l~e5~d211t <br />State of C~bt'dd~ 1 <br />A ' ) ss. <br />County of /tLuG11719 ) <br />Signed: <br />/fss~z~ -Corporate <br />Town/City/County Clerk <br />Thee f~oregoing instnnnent was aclmowledged~ef~ore me this ~n~ day of V LL n .t (J <br />by1Y~r~pl L~). ~~~-„-~- as i'fQ~il~n.~.~ ofd~s~~l-v~.l-4 S~o~ial+;as .~~.n~_ <br />Notary Pu c <br />My Commission expires: ~(/- ~~-d~ <br />SIGNATURES MUST BE IN BLUE INIi <br />1/2005) <br />~ Cet+ E~ tarr.u, <br />