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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 <br />of 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 <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 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 applicantloperator, 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 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.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 44 day of DA-l» h2 & o f?' , <br />-RQ_Blanco County <br />Applicant/Operator or Company Name <br />Signed: <br />Title: o ?? fi B Q r o C& o P.n, wn-r a_ <br />Stateof- ?d/dr?ct'o } <br />) SS. <br />Countyof Ri'o BLaneo ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />'l'ire foregoing instrument was acknowledged before me this _ aid day of _-D_0_ e2oo <br />_Rbn ? as .. ?I.. rd, of -- ?__-L8 ?a1'? cJ r?#1¢ <br />` #10 ?Z <br />+o.r <br />:N? e.- <br />Pu <br />Commission expires:. 3L3_0_L0,q„____ <br />SIGINATUIgyq?l ST B. JE INK