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• <br />Certification: <br />-8- <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements <br />of 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 <br />this 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 twining 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 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.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 <br />made herein are punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />• <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-Jl2,C.R.S, of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form 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 penalties for operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this 1?0 day of Q C' <br />, <br />A APA00) ffi WSg)k wis z <br />Applicant/Operator or Company Name <br />Signed. _ kA6L P AtA- <br />Corporation Attest (Seal) <br />If <br />Signed: <br />Title: r- <br />State of C.OC.K A_aO2.o <br />) ss. <br />County of Wkl.141 <br />_ ° ---' - -- - -- ,t <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this day of <br />Q , by of &-o A., aAA., .Q <br />Notary Public <br />c <br />i?'? zi M Commission expires: 6 2 t { ' Mr 6Z, P• <br />SIGNATURES MUST HE IN DIAX INK <br />1"' A <br />I firiti:4141,?', <br />??