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-8- <br />Certification: <br />As an authorized representative oPthe applicant, I hereby certify that the operation described has met the rninirnum 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) in existence at the time <br />this application is flied, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 3432.5-t 15(4)(e}, C.R.S.). <br />Z. i'~lo 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 riot have any extractionrexploratian 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 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land ReclamationBoard pursuant to section 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation fief for the Extraction of Construction Materials. Ai:y alteration or modifcation of this form shat! result in voiding any <br />permit issued on the 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, CR.S. - <br />Signed and dated this ~~Q-~ day of ~t° bruo-r7 , ~O ~ , <br />l.(~j111 II ~° 1 1') AYI~ S~YI rJ' ~~C. if Gorporatian Attest (Seal) <br />Applicant/Operator or Company Name - : `~ \ <br />Signedr.;>h-b..,~ %T- ~.,~~.,~~ ~c.c/~'L <br /> <br />State of ._-~ ~Q `G~C,~---Q --____-} <br />t:"ounty af _....__....1....1..Q..~..1.1,.....1....1..._..._.........._..._...........,t <br />'1"1-~e tc,r~:gasrg tnstrument was ackrn~aiedg~:c ~r~:ft,re me this <br />s ~ ~. <br />e , ~,} <br />~~~' ~~ <br />F ~o~• ~ s v <br />.a <br />~~°~o~oo <br />Signed: tiv <br />Corporate Secreta or Equivalent <br />Town,~City/County Clerk <br />of----~e ~_roar._ ..... _.---_-----~ <br />~~fGr~rY;~ 1~~~'~ A~ ions _=nC. <br />~~a: r <br />Public <br />Commission expires:. _.1__~..._-...I...~._-.Q~.. <br />stc~:~~r~~z>~;s ~rv~~ I3~, i:~ >3y:c~1~, i~tz <br />