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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certifythat 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)(1), 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 arc 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.JRS., 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 modif led 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, CR.S. <br />Signed and dated this 641' day of e'G ?&?A- ' -40Y <br />/?C ?1 t A 4 / a' [ ? ` <br />Applic t/Operator or Company Name u <br />Signed: <br />Title: jn' j <br />if Corporation Attest (Seal) <br />5` <br /> <br />Signed: Z.5? <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />Statc of.-? <br />d - 1 ) ss. <br />C'ourty of ....) <br />f 11V fiyreg?+ insttwneiit was ack?no ledged before me s t- -Ei' day of Lc. 4. 2 c . <br />lay` •- ??U?r1'?? -ta_? -..? ? ``??.?r?? ?or•- L ??. .1? .. <br />A f, <br />r Notary Public <br />My Commission expires: <br />SIGNATURES MUST BE IN 131-t?E INK