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<br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minunum requirements <br />of the following terms and conditions: <br />1. To the best of rtry knowledge, all significant, valuable and permanrnt mart-made structure(s) N existence at the time this <br />application is filed, and located within 200 feet of the proposed affected azea have been identified in this application <br />(Section 34-32.5-1 IS(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operations are prohibited by law (Section 3432.5-I I5(4)(f), <br />C.RS.; <br />3. As the applicant/operator, I donor 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 (Section <br />34-32.5-120, C.R.S.) as determined through a Boazd Ending. <br />4. I understand that statemrnts in the application are being made under penalty of perjury and that false <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. ~ <br />Signed and dated this J~ day of /~~ 1O"2~~~, , <br />L.G <br />Title: <br />n , <br />State of " <br />~I - ) ss <br />County of )1 ) <br />Borate Secretary or Equivalent <br />Town/CirylCountyGlerk <br />Th going instrument was acknowledged before me this ~ ~~~ day of ~ l l ~~U' <br />I' '9 <br />b}J ` I~'k ~i "PIl ~~r as L~ IC` • I)(r""`~A~c-,^i,L~" of 1t. ~ ~i~e//<'~f <br />~. lt-t~c~-- <br />Company Name <br />,7 <br />SIGNATURES MiUST BE IN BLUEm. E~ItMJm.1,P002 <br />