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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 />t. To the best of my knowledge, all significant, valuable and pennanent 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 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 applicantioperator, 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 />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 modi, fled form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-32.5-113, CRS. <br />Signed and dated this day of / "/ yL'& 2I s5t , ZC <br />Applicant/ Operator or Company Name <br />Si ped - <br />::::! <br />Title: <br />State of <br />) ss. <br />County of .---- _ ........ _._..-....__.) <br />i he f{ r: g <br />ument was acknowledged befort <br />by as <br />A60b by <br />If Corporation Attest (Seal) <br />,%%I 1808tt" <br />.`???JgAN K ?c` <br />Signed: e <br />ir3T t Corp to Secre or Equivalent <br />y Town/City/County Clerk <br />???Itllill?? <br />i1 <br />My Commission My p MMOSIM WM-S fia1171M <br />SIGNATURES MUST HE IN HI.,[X INK