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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 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)(f), C.R.S.; <br />3. As the applicantloperator, l 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 34-3Z.5-112,C.R.&, of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials Any alteration or modUkadon of this form shag 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.JL& <br />, ?. <br />Signed and dated this L? day of JuA cl <br />Yuma County Road and Bridge <br />Applicant/Operator or Company Name <br />Signed: '4t <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: R.ad_ttiparvi Rnr <br />Town/City/County Clerk <br />State of Cot d paj o ) <br />ss. <br />?? ) <br />County of yu tn <br />`The foregoing instrument was acknowledged before me this 14 day of <br />Zp 4c[by?ARX 5AIA&d as. RcAdsuPoRlliSa2 of tfMA `ac?rvey c6ZZ? <br />F NOTARY PUBLIC Notary Public <br />STATE OF COLORADO O f <br />HC'A!XVID V WGINNIS <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK