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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) 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)(t), 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 Constriction 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 I8-8-503, C.R.S. <br />This form has been approved ky the Mined Land Reclamation Roard pursuant to section 34-32.5-112,CR.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. ,guy 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 />Signed and dated this day of <br />If Corporation Attest (Seal) <br />Applicant/Operator or CompaXName <br />r <br />Signed: Signed: <br />- Corporate Secretary or Equivalent <br />Title: _ t 1414-1 G - Town/City/County Clerk <br />State of <br />J l ) ss. <br />County of .j <br />foregoing instrument was acknowledge.i Inctni me this <br />Che <br />MANDI <br />SMUTS <br />My Commission Expires <br />06/12/2010 <br />.it'S-I lip' IN II'E iNA <br />My Commission expires: L- 1 _14-71 (-1) _.