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-8- <br />Certificadon: <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) 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 applicantloperator, I do not have any extraction/exploration operations in the State of Colorado currently in <br />violation--of the-prmrisions-of the- Colorado Land-Pxcl_aam-tiou Act for_.tha 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 fora has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modl, kadon of this form shag result in voiding any <br />permit issued on the altered or moth led form and subject the operator to cease and desist orders and civg penalties for-operating <br />without a permit pursuant to section 34-32.5-123, CJL& <br />Signed and dated this fib day of ?,V A.°/ <br />Yuma County Road and Bridge <br />Applicant/Operator or Company Name <br />Signed: - ?A. 'J' <br />Title: Rnatl gnparyi Rnr <br />- -- - - - - - <br />State of CD D IAA D ) <br />ss. <br />County of ?n ) <br />If Corporation Attest (Seal) <br />.? <br />Signed. <br />Corporate Secre(Jy or uivalent <br />-ielyACounty Clerk <br />The foregto?inng instrument was acknowledged before me this 14 day of J-a4 , <br />Zt7 b`L_, by 11? AR .S AHJ as . RoAcl SupW/Z 11,13111Z of )/ a MA Ca cc•yT G6 ZD <br />NOTARY PUBLIC Notary Public <br />STATE OF COLORADO <br />L-------HO W. 'gin sicGIwNIS My Commission expires: C "3 - 4O / ig <br />MY r:•'-ZO12 <br />SIGNATURES MUST BE IN BLUE INK