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-~- <br />Certification: <br />As an authorized representarive of the applicant, I hereby certify that the operation described has met the minimimr requirements of <br />the fallowing terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) inexistence at the time this <br />application is fled, and located within 206 feet of the proposed affected azea 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 applicanUoperator, 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.) as determined through a Board fording. <br />4. I understand that statements in the application aze being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.RS., ojthe Colorado Land <br />Reclamation Ad jor the Extraction ojConstruction Materials. Any alteration or modification ojthis form shall resin! in voiding any <br />permit issued on the altered or modifiedform and subject the operator to cease and desist orders and civilpenaLies jor operating »bhout <br />a permrt pursuant to section 34-32-123, GRS. <br />Signed and dated this ~~- day of T~LY <br />ApplicanUOperator or Compaq Name <br />Signed: <br />r <br />Title: <br />State of ~,~e~ <br />ss. <br />County of <br />7,~L <br />~Ct~ <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this ~ day of. <br />30 ~ F u c as i'LIe~ of <br />~,gPNA(~~1J(y THE <br />• Notary Public <br />M <br />_ _ My Commission expires: <br />%. <br />. ~` <br />SIGNATURES MUST'BE IN BLUE INK <br />by <br />ZyDc{ <br />M:MmWveNd'ormalCo~smwti®112doc (05262004) <br />