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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 mires ?*n <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 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. 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 3¢32.5112,GILS, of the Colorado Land <br />Reclamation Act for the Extraction of Construction Material& Any alteration or moth, flcadon 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 fgnoperating <br />without a permit pursuant to section 3¢32.5--123, CR.S. <br />Signed and dated this 21 day of Ec,o c ,16 '2 OF of <br />9 f <br />I-Z-7 Co H s e.- '4 a r, -1 .rte c , <br />Applicant/Operator or Company Name <br />Signed: <br />/S4 s?c..r <br />5 f'c/ Ile. <br />Title: /; ?- e s : J. <br />If Corporation Attest (Seal)',., <br />Signed-ice-- <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of co/" ,- -a 'A ) <br />ss. <br />County of e s c,-- ) <br />The foregoin instrument was acknowledged before me this ? day of 3& ? 43411-1 <br />. by ok,e. as try of E-40-" _ C-&M4-h - <br />®``nQ Notary lic <br />A Notary ? <br />AZ ? <br />My Commission expires: 5 7-O <br />.4c -? - <br />7 <br />Nr 'OUb11° O <br />SIGNATURES MUST BE IN BLUE INK <br />OA a ry <br />? g 1 %W 4otices at the location of the proposed mine site to clearly identify the site as the location of a <br />°4 Expires