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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 applicant/operator, l do not have any cxtmetion/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 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 Redemadon Board pursuant to section 34-325112,CRS., 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 mod(/ied form and subject the operator to cease and desist orders and civil penalties for operaAng <br />without a permit pursuant to section 34-32.5-123, C ILS <br />• Signed and dated this ' day of e- <br />W _ r if Corporation Attest (Seal) <br />Applic t/Opcmtor or Company Name <br />r <br />Signed: --f Signed: <br />4- A14-d- <br />Corporate Secretary or Equivalent <br />Title: e , TownlCity/County Clerk <br />State of._? <br />County of_.??. <br />'I lie tbrcgc? a insttument was aehno ledyed twf'or4 me ts day of t <br />by r etc <br />:= <br />_4 _ - - C..... <br />777->?Q. r--N k 0_ 4A <br />Notary Public <br />My Commission expires: <br />• SIGNATURES NICEST BE IN BLUE INK