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D <br />-g- <br />Certification: <br /> <br />As an authorized representative of the applicant,) hereby certify that the operation described bas 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 %vill be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), 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 Mined Land Reclamation Boardpursuant to section 34 325-112,CR.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Material& 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, CR.S. <br />Signed and dated this C %Q v* day of /0"417 06 '9 . <br />Z.r? f 4 ?/rllfiZref?a?e1 U?dt12&eeL If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Signed <br />Signed; <br />Corporate Secretary or Equivalent <br />Title: (0 4,.J[4e- <br />State of eblora&o ) <br />)sq. <br />County of tt } <br />Town/City/County Clerk <br />The foregoir_g instrument was acknowledged before me this 3O day of ?'_&_) <br />= by hJ BO K-l_ as ?.?S?L - ... _ . . _ _ or Ac3 50fli CQA5 nr Ch=tGh3tue1 <br />n . .?.?+n. <br />TPIRI A. STEPHENSON <br />NOTARY PUBLIC Notary Public <br />STATE OF, COLORADO <br />My Commission expires: q ' 7_„z ?l <br />SIGNATURES MUST BY, IN BLUE INK