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-8- <br />Certification: <br />?s an authorize(4 representative of the applicant. I hereby certity that the operation described has met the minimum <br />requirements ol'thr tollo\ving, terms and conditions: <br />1. I'o the hest otmy knoyvlcd_,e, all siunificant, valuahlc and permanent ratan-nrade Structurc(S) in e\istence at the time <br />this application is filed. and located within 200 feet of, tile proposed affected area have been identified in this application <br />(Section 34-32.5-115(4)(0. C'.R.S.). <br />No Illllllll`? operation wi?I he located on lands where Such operations are prohibited h\ lass <br />( Sect ion 14-32.5-115(4)(1). C. R.S.: <br />3. As the applicant!opcrator. 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 120. C.R.S.) a" determined lhroU_h a 1 OArd finding. <br />4. 1 understand that statements in the application are being made under penalty otperlun and that false Statement" <br />made herein are punishable as a Class I misdemeanor pursuant to Section 18-8-303. C.R.S. <br />This form hus been approver/ hr the ilined Land Reclamation Bourd punttant to section 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation . t ct for the [,straction of Corrstruc•tion ilaterials. -t nt' alteration or modification of this form shall revelt in voidin.l uttr <br />permit issued on the ahered or modified form and subject the operator to cease and desist order and civil penaltiv% lor operutin., <br />without a permit pursuant to section 34-32.5- 123, C.R.S. <br />lr ?L`y <br />Sl'rled and dated this das of <br />Martin Azcarraga <br />Applicant' Operator or C'ompam Name <br />Siuned: 7 <br />Title: Owner <br />Ii'Corporation Attest (ticall <br />Signed: <br />Corporate Secretary or I quivalent <br />"fown'Cit) C'ount\ Clerk <br />State of (J `v' l(?d r ) <br />ss. <br />County of <br />The furc_oine,, instrument /w? was acknowledged hetore me this (ias of <br />UGC` . by f YILIr-1 r r71 z-(?kLY e as of X f re- <br />Cor?1r <br />Notars Public <br />- r-/ / <br />\4y Commission expires: ex <br />SICNATf; Ri'S NIUST BE IN BIJ F' INK <br />YOU must post Sufficient Notices at the location of the proposed mine site to clearly identik the site as the location of a