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-8- <br />C:.ertlf cation: <br />As an authorized representative of the applicant, I hereby certify that the operation described has mgt the nninimurn requirements <br />of the following terms and conditions: <br />1. To the best ofmy knowledge, all significant, valuable and permanent rman-made structure(s) inexistence at the time <br />this application is filed, and located within 200 feet of theproposed allbeted area have been identified in this application <br />(Section 34-32.5-1 15(4)(c), C"'.R.S.). <br />?. No mining, operation will he located can lands where such operations are prohibited by lacy <br />(Section 34-325-115(4)(f), C'.li.S.: <br />3• As the applicant.'Opci-ator, I do not have any cxtracticrn:`exploratic}n operations in the Settle of Colorado currently in <br />violation of the provisions of the Colorado Lane( Reclamation Act. liar 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 f misdetnc n7or pursuant to.Section 18-8-503, (,'.R-S. <br />This /'coin has been approved by the Mined Land Reclamation Board pursuant to set-lion 34-32 5-172,C.R .S., uf'the Colorado Land <br />Reclamation Act for the Lxtracrinn of C"onstructiou Uaterial s. Any alteration or modification of this form shall result in voiding any <br />perinit issued tin the altered or modifred form acrd subject the operator to cease and desist orders and rivil psn ItiesJnr operatiuS <br />without a permit pursuant to section 34-32.5-123, C'.R.S. _ ? - <br />Signed and dated this day of .................................. __..............., ........r?7GU... - _ <br />..... .....................J...__.. ...?__..._? '• <br />l? <br />Applicant/Operator or Cori pony blame <br />Signed: -. ......... <br />.Title:... Nla?5--dev-d7... <br />If Corporation Attest (Seal) <br />/ <br />Signed: <br />_..-?. _(..Y <br />--- <br />Con )rate ecretary or ('quivalent <br />Town/C:"ity/C'otntty Clerk <br />State of ..._?.Ca__.___. :.,_...?..._..._t <br />9 ,, 1 ss. <br />frr €Ia 139 <br />115e ., r,ft: -F tr:?aPttmet t sv415 aekr?{;.i l , 'I r ?rC' tT this C, <br />??s?H?- ,L I/?rra OL (d <br />Notary Public <br />My Cot MIsston expires: <br />IC:? VVI I21,I's 111"`T liv; US 111,11T IN