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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 conditions: <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.R.S.). <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.R.S.; <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.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application are 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.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.RS., of the Colorado Land <br />Reclamation Act for the F-xkaction of Construction Materials. Any alteration or modifu:ation of this jorm shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penabies for operating without <br />a permit pursuant to section 34-32.5-123, C.RS,, <br />Signed and dated this a" ~ day of t ~i (~'t/ e~~ ~ ~ ~ ©©~ <br />Albert Frei and Sons, Inc. <br />ApplicanUOperator or Company ame <br />~~ ~> <br />Signed: <br />Title: President <br />State of Colorado ) <br />ss. <br />County of Adams ) <br />If Corporation Attest (Seal) <br />r <br />;~ <br />~~' c s <br />r A _ s+ <br />Signed: "'~.. <br />r ~ ~, <br />r ~ ' <br />Corporate Sec~tafypr Eiluivalent -~<~ <br />~,~.. =r. <br />= ' °- <br />Town/Ciry/Couaty'elgrk- ' ~ ' ~~~ <br />H°e , ate` *a <br />~ ~ t~ `\~1 <br />The foregoing instrument was acknowledged before me this _ ~}~ day of ~~U2nn_ ~- , <br />by Albert R. Frei. Jr. as <br />$$ qqx 4r r~ 1 ~ ~ ¢ w <br />~yj ui~.~i~°i ~ L,8 a f~~ is9,Ci"~ 6,Ji..t 1 <br />,~l eRtgg,` 7 o PY 1 ,,lrrt j.~ ~ F ..3 ~ f .f~~^yy <br />~~ S,~' ? t [ k e... ~ I" Ems' 4 7 f«`.% ~i'~7 Yk•'6S: ~! w <br />.1 t! ~.h ri\ ~e rnE dpi ,,r~"1 a'"n4~ <br />of Albert Frei and Sons, Inc. <br />My Commission expires: ~d--~~ ~~~ <br />'~ <br />SIGNATURES MUST BE IN BLUE INK <br />