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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 <br />requirements 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 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 Board pursuant to section 34-32.5-112,GR.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or moderation of this form shall result in voiding any <br />permit issued on the altered or modled form and subject the operator to cease and des pt orders and civil penalties for operating <br />without a permit pursuant to section 33 -33--123, GAS <br />-Ty <br />Signed and dated this . ") day of <br />Applicant/Operator or Company Name <br />Signed: <br />Title: AJMLVIFZ???? - <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of C Cho-tc'd 6 ) <br />ss. <br />County of Ica W \Q-1A ) <br />The foregoing instrument was acknowledged before me this Lo day of N y?C -OA <br />ao<!R by Q)k_p_ 1, (_0 as 0 ?C'n o K6oi of V\dZu' J _ S) ? C1 k (? c,.,J <br />Lc (?) CW c 0 <br />=NOTARY IS Notary Public <br />LIC <br />SRADO My Commission expires: a ` D-a- 0a <br />SIGNATURES MUST BE IN BLUE INK <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a