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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 ofmy 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 34-32.5-11 5(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)(t), C.R.S.: <br />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. 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 I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This fornn has been approved by the llined Land Reclamation Roard pursuant to section 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation Act for the Evraction e!f Construction Materials. Ant• alteration or modification of this form .shall result in voiding anY <br />permit issued on the altered or modifced Jorm and subject the operator to cease and desist orders and civil penalties fur operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this day of Nov beoe_, <br />R(M' 110,Ve C0et? y? r t4 0(C( T I ` <br />l ?? ?? I f Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Signed: ;- <br />Title: President <br />Signed: _ T <br />Corporate ecrc ry or Equivalent <br />Town/City/County Clerk <br />State of cl"O54n2 ) <br />County of is kQ / v Gc <br />The toregoin?stru ent Aws acknowl dged before n x this day of Aw-em ?`r? <br />a05?5 by 2 /eQ as of t?( ' 4rV Q G.2? v ?P ¢- <br />Toe tecy <br />0 -1-4 <br />Notary Public <br />My Commission expires: <br />. <br />SIGNATURES N111sT 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