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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)(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)(f), C.R.S.; <br />3. As the applicant/operator, I do not have any extract ion%expIoration 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 periury 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 b?' the Mined Land Reclamation Board pursuant to section 34-32.5-112,CR.S., of the Colorado Land <br />Reclamation. t ct for the Extraction of Construction Materials. ; t n y alteration or modification of this form shall result in voiding aikv <br />permit issued on the altered or modified form and subject the operator to cease and desist order and civil penalties for operating <br />without a permit pursuant to section 34-32.5-123, C: R.S. <br />Signed and dated this dO T day of 7. <br />If Corporation Attest (Seal) <br />Applicant/Ope or or Company Nam : _T COQ <br />Signed i Si ed: <br />i Corporate Secretary or Equivalent <br />PZ Title: Town./City/County Clerk <br />State of V W t OL C• <br />O <br />ss. <br />County of ) <br />l '1 <br />Olt- MY in?ment wa, acknowledged before me this W14 day of <br />Ol Z• uY as 1!?(llr INL(?i.? ? of <br />Notary Public <br />My Commission expires: aq?c ' 'J/c " oil <br />SIGNATURES 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