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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. Fo the best of my knowledge, all significant, valuable and permanent man-matte structure(s) in existence at the ti me <br />this application is tiled, and located within 200 feet of the proposed alTcctcd area have been identified in this application <br />(Section 34-32.5-1 15(4)(e), C.R.S.). <br />2. No mining; operation will he located on lands where such operations arc prohibited by law <br />(Section 34-32.5-115(4)(1), C.R.S., <br />3. As the applicanuoperator, I do not have any extraction.' exploration operations in the State of Colorado currently in <br />violation of- the provisions of' the Colorado [.and 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. 1 understand that statements in the application are being made under penalty of penury and that false statements <br />matte herein arc punishable as a Class l misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation hoard pursuant to section 34-32.5-112,CR.S., of the Colorado Land <br />Reclamation ,4ct for the /i.rtractiorr of Construction ,Materials. An * I- alteration or modification of this form shall result in voiding ark t• <br />permit issued on the altered or nrodifted john and subject the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant rosectlIion 34-32.5-123, C.R. S. <br />Signed and elated this t -- day of ?k., C,L' <br />IfC'orporation Attest (Seal) <br />'1'/?( "'? F t ti' i• tee tti'e <br />Applicant/Operator or Company Name <br />Signed: , Signed: rz-tom, L.1_" C? <br />Corporat Secretary or Fqui agent <br />Title: Towri'CityCounty Clerk <br />State of .-- --'___-. -_-_--- -) <br />`n ) ss. <br />County of ^ r 1?? - ------) <br />['he foregoing instrument was acknowledged before n>< this ---? --_ clay of <br />`J <br />by t ti:t 1 i r? Z??cA!^3^Cl?' C.?a, t'S l`\4? 1\ of ..?Gt??t C. ?t;Ct7 <br /> <br />-: •P <br />aVJDw <br />N . <br />t? <br />?_, <br />t ?., <br />1 <br />Notary Public 1 <br />My Commission expires: <br />BF IN Ill I I- INK