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-8- <br />Ccrtitication: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements <br />of the lallowing terms and conditions: <br />1. To the best of my knowledge, alI significant. valuable and permanent man-made structure(s) in existence at the time <br />this application is tiled, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-1 I5(4)(e), C.R.S.). <br />2. No mining operation will he located on lands where such operations are prohibited by law <br />(Section 34-32.5-1 15(4)(t), C.R.S.; <br />3. As the app] canvoperator, 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. 1 understand that statements in the application are being made under penalty of pet_ jury 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 Nee Alined Land Reclamation Board pursuant to .section 34-31.5-111,GR.S., of the Colorado Land <br />Reclamation ; Ict for the Extraction of Construction Materials. Ate y alteration or modification of this form shall result in voiding any <br />permit issued on the altered or tnodified form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34-31.5-113, C.R.S. <br />Signed and dated this day of a pry ?. <br />Appiicant.'Operator or Company Name <br />Sign L?? <br />Title: C?e_L,1-at ?-- <br />State of C - ; . - - -- -) <br />ss. <br />County ot"Yyjay-Zal. . .) <br />I he t'orc going instrument was acknowledged before <br />ao q by ; ?n w % l S Un __ ..__ - as! <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town City County Clerk <br />day of - <br />rw-f of ro On' <br />KATN\, r. <br />V1. <br />%Iv Commission expires: -? S-130/6 <br />slWN 1 fI RFS Nil ST lip' IN I11.14.. INK