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-8- <br />Certifleation: <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) inexistence 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 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 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Boardpursuant to section 34-32.5-112,f R.S., of tire Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. 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 permitpursuant to section 34-32.5-123, CR. S. - i j <br />Signed and dated this day of 41 v? Go C1. . <br />N# G'o"oG???-F C2?N u? ivr.?, r?1c <br />Applicant/Operator or Company Name <br />Signed: --- <br />Title: _?LQi?ery <br />State of ) <br />) ss. <br />County of <br />The foregoing instrument was acknowledged before me this day of <br />. / <br />_Z_C'4f rQ? a5 ..- `f <br />by r'LL.:.t^_}!------- f.J <br />of <br />RY PNotary Public <br />My Commission expires: ,c_ ...... .......... ........... ..... _................ <br /> <br />If Corporation Attest (Seal) <br />HE IN BLUE INK <br />Signed: <br />Corporal Secretary or Eq alent <br />Town/City/County Clerk <br />Q <br />1 ? ¢"1