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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) 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(4xe), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 3432.5-115(4xf), C.R.S.; <br />3.. 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. 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 />Thu form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,CRS, of the Colorado Land <br />Reclamation Actfor the Extraction of Construction Materials. Any alteration or modification 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 for operating <br />without a permit pursuant to section 34-32.5-123, CRS <br />Signed and dated this ? I day of ou eq mbege <br />Q ? g <br />If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Signed: <br />Title: President <br />Signed <br />Corporate ecre or Equivalent <br />State of 1 <br />) ss. <br />County of g ) <br />The foregoing ins ent w acknowl dged before this day of <br />AMA by ash <br />Notary Public <br />TownlCitylCounty Clerk <br />ave <br /> <br />My Commission expires: /.1 /-2?)/.--2 <br />t <br />SIGMA- UJRES WST.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