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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, 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 34-32.5412,C.RS., of the Colorado Land <br />Reclamation Ad for the Extraction of Construction Materials. Any alteration or modif lcation 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, CRS. <br />e) 0 <br />Signed and dated this day of V C/ `( <br />Yuma County Road and Bridge <br />Applicant/Operator or Company Name <br />Signed: <br />If Corporation Attest (Seal) A4djovl= <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: Road gupervi cnr <br />Town/City/County Clerk <br />State of C64ORA?0 ) <br />ss. <br />County of 14 /n .4 ) s <br />The foregoing instrument was acknowledged before me this 16 day of '- <br />0 0 9 ---> by - as. oqa? SuPE2lJiso2 _ _. _ of yom'd -C01.y _ ca _16 <br />-----------------------------"""" <br />NOTARY PUBLIC Notary Public <br />STATE OF COLORADO L'?- <br />HOWARD V McGINNIS_ My Commission expires:._ / ?_?- <br />MY COMMISSION EXPIRES _ - - <br />SIGNATURES MUST BE IN BLUE INK