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<br />-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), CRS.). <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.RS.; <br />3. As the applicantloperator, 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.S-114 CR1, of the Colorado Land <br />Reclamation Ad for the P•xtr acdon of Construction Materials. Any alteration or modification of this form shall result in voiding any <br />permit issued on the altered or modifled form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permirpursuant to section 34-32.5-123, CRS. <br />Signed and dated this (-P day of W&4 <br />Applicant/Operator or Company Name <br />Signed: <br />1 <br />Title: <br />State of (.L'+f-o' J I ) <br />ss. <br />County of 1 T) zkvm ( ) <br />The foregoing <br />tma),by - ! <br />My Commission Evims <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />My Commission expires: (a-12--l <br />.