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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-trade 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 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. 1 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 Boardpursuant to section 34-3Z.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 />t , z ovf <br />Signed and dated this T?.? day of A toy , <br />CAP "..1LU(_ <br />Applic Operator or Company Name <br />Signe <br />Title: <br />State of.. ( C: V Ck <br />) ss. <br />Count of - wr-..-..._-.-.-._..__._._... -) <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before nit this ...__.'? ---._... _._. day of --._1-VoLle m -er_ <br />_...5 <br />2 4 by.-_?(, -C - -- - -s?-.?_ --...-- - -- - - as C---v?C -_ 'r......--.....---_---_.__-------- of -._V._N. c -vac CS-._,.- -L ............... <br />PM EC •-.,; Notary Publ c <br />NOT ?'r <br />'GO <br />- <br />s m A?B? <br />%O lC <br />??rrrrnnu?????? <br />?S 10-27-2009 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />My Commission expires:.I ?-7_ <br />SIGNI .4, I UTRES MUST BE IN BI..1 TE INK