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('ertif ication: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the ('ollowing 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 tiled, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-1 15(4)(c). 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)(1), 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. 1 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-K-503, C.R.S. <br />Thi.s• form has been approved bi• the Mined Land Reclamation Board pursuant to section 33-32.5-112,CR.S., of the Colorado Land <br />Reclamation ; tc•t for the L••xtraction oj'C'oprstruc•tiorn ,date rials.: nY alteration or modijic•ation of this form shall result in voidinr; anp <br />permit i.s.sued on the altered or ?nodijied jorm and suhjec•t the operator to cease and desist orders and civil penalties for operatinn <br />without a permit pursuant to section 34-32.5-123, CR.S. <br />Signed and dated this .Z 1 day of ??? c .? 6? r o a 9 <br />?/a a_,s7 C. O H S ?? L T Jri fir. C , If Corporation Attest (Seal) <br />Applicant/Opcrator or Company Name <br />Signed: SignedL' <br />t`I' h` r` ?"'?`'`` Corporate Secretary or Equivalent <br />Title: -2r e s c?f'e .? Town!City/County Clerk <br />State of (f lc c< ' <br />y? ) ss. <br />County of ii!jG S li- ) <br />The foregoingcc instrument was acknowledged before me this ? day of ?tc- r'yt io-c-? <br />by V t ('t tom-- ?C aAJ DC?r__ a s ?h.c "l e . o f ??a-wr Ce yt ?5?yc s e. t 6f'? <br />????N`?? Hp??i??? Notary Pt tic <br />?O t pry ?G <br />My Commission expires: S Zol <br />SOU b 1 <br />0??? ??, SIGNATURES INIUST BE IN BLUE: INK <br />? ? o <br />? ? mI e1?`?'votices at the location ofthe proposed ntinc site to clearly identity the site as the loratiim of a <br />h Expftes ?b