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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)(1), C.K.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 1 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 KS., 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 />Signed and dated this yd?t , day of <br />`'?-'' <br />Applicant/Operator or Company Name <br />L ^ r <br />-?---? C <br />Signed: <br />A4- <br />Title: <br />1 <br />State of l tZ ) <br />} ss. <br />County of r--, MANDI ; <br />SMUTS <br />F??•COid?? <br />The foregoing instrument was acknowledged before me this day of <br />Y <br />My Commission Expires <br />06/12/2010 <br />If Corporation Attest (Seal) <br />i??usi PRoulp CoRP 5> <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />Notary <br />My Commission expires: <br />SIGMA ES MUST BE IN BI:CiE INK