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<br />-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) inexistence 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 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 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 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 without <br />a permit pursuant to section 34-32.5-123, C R.S. <br />Signed and dated this day of ayj <br />Yuma County <br />Applicant/Operator or Company Name <br />Signed: 0"ci Title: Road Supervisor <br /> <br />State of Colorado <br />County of Yuma <br />) ss. <br />If Corporation Attest (Seal) <br />Signed Any . _ <br />Corporaetary ,or_- Equivalent <br />Town6unty Glgsk <br />The foregoing instrument was acknowledged before me this W P4 day of A y , <br />by Mark Shaw as Road Supervisor of Yuma County <br />J J V J <br />W, V-1 <br />Notary Public <br />My Commission expires: /J?D y <br />SIGNATURES MUST BE IN BLUE INK