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-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 stricture(s) inexistence at the time <br />this application is filed, and located within 200 feet ofthe proposed affected area have been identified in this application <br />(Section 34-32.5-115(4)(c), 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(4X#), CLL.; <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, CRS. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34 31 S-112,GRS., of the Colorado Land <br />Reclamation Act for theExtracdon of Construction Materials. Any aiteration ormodificabon 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 c(PH penalties for operating <br />without a permit pursuant to section 34-315-123, GR.,& <br />Signed and dated this 1 day of L2 . <br />Moffat County Board of County <br />.'Weantl r or Company Name <br />,'l'itiir? 1 YVlQ ftcc- <br />State of=_.r?? Cyr °? ) <br />) ss. <br />Commiss ioner?f Corporation Attest (Seal) <br />Y 0 tXT C9 <br />ti <br />s <br />SE.t+ L ; <br />OR Ap? <br />County of VAP `d ) <br />rporate Secretary or Equivalent <br />Town/City/Co Clerk <br />The foregoi g instrument was acknowledged before me this. I L4'*-- day of <br />a &C5 by as . 111 ?u +Ce -- of <br />Nat'ary ublic <br />My Commission expires: qI-Ago-J2 e 14 <br />SIGNATURES MUST BE IN BLUE INK