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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) 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 I 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 34-32.5-112,0 RS., of the Colorado Land <br />Reclamation Actfor theEiaracdon of Construction Material% 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 permit pursuant to section 34-32.5-123, C.RS <br />Signed and dated this day of S .P h 1,e vn ? <br />_A S,. #0 ?? rrX b4 goo 54 <br /> <br />Applicant/Operator or Company Name <br />r' <br />Signed: <br />Title: <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of a,l? <br />Jf ) ss. <br />County of The foregoing instrument was acknowledged before me this ? day of .o - i- <br />a&& by o)gs -1-et- eye ,or, as ??c of "'5 <br />V??(? <br />.;;P. <br />Y <br />SAND Notary Public <br />W- RAS, <br />?. My Commission expires: <br />V Pp <br />4 <br />S 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