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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 <br />requirements of the following terns and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent 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)(0, 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 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 mody1cation of this form shall result in voiding any <br />permit issued on tire 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 day of / UA9- , 2U0 5- <br />1 <br />u' ?? 14,If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Sign( <br />Title: <br />State of <br />) ss. <br />County of <br />Or? qr1 <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me thi day ofU a X1.2. <br />2005, by 5 S. I r n e? as d4 9M f- of <br />\ (t v, <br />,o y d ?I <br />?..' =. '`Y o ublic <br />V ^ - My Commission Exp <br />?? o r `? aa rJ My Commission expires: 00=7 <br />a <br />SIdl,4A SWiL AtE IN BLUE INK <br />a® <br />A1:limn\charelvsformslConsttuction 112.doc (Approved 05/1 1/2005?'%rpprrtra:et?Ai