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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, I do not have any extractioniexploration 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 Hined Land Reclamation Board pursuantt to section 31-32.5-112,C:R.S., 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 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 />?i?C'/y d4 <br />Signed and dated this lp Z? day of <br />Applicant/Operator or Company Name <br />Signed: <br />o ? <br />Title: <br />If Corporation Attest (Seal) <br />.ic a (?1 ? Im(L <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State o f ._ O_o JO rO_'O UO --- --- -- -) <br />) SS. <br />CGBrntt of Q............_......._.......-......._.. ...................3 <br />i"he foregoing instrument was acknowledged before me tl >s ... /C .............. dayof -.`_/.-Oe-rC.?.h...-----........__..--- <br />,_ ------. f <br />? -??¢ v? <br />t by _.._Jack P. -./_`llc__?--a.?_?...._ of [---C4 _ <br />T ?......_....._....-.-.._. <br />- -- <br />`yf'1. <br />Not Public <br />My Commission expires: _5/1a/o ( <br />SIGNXr RES MUST BE IN BLUE ILK