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-8- <br />Certlfieati": <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.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 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 I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mixed Land Reclamation Boardpursuant to section 34-325-112,CRS.-, 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 day of X_" _• <br />Applicant/Operat Ar Company Name <br />Signed: <br />Title: fi AO- <br />IfCorporation Attest (Seal) _ <br />Signe <br />orporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of _ , `-) <br />County of <br />'LB? T ._. ) <br />'rho foregoing instrument was acknowledged before this day of .?-9J 9 <br />by _1r of`!' r r ,i' i X;.L nc <br />`DENI'SE. ? NYAtES ? Pax <br />STATE OF COLORADO, <br />My mmissioa ices t) No ry Public <br />My Commission expires: 7Of'? <br />SIGNATURES MUST BE IN BLUE INK