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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(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 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 detennined 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 form has been approver/ by the.4lined Land Reclamation Board pursuant to section 34-32.5-112,(.R.S., of the Colorado Land <br />Reclamation Act-for the Extraction of Construction Materials. A»r alteration or modification of this form shall result in voiding any <br />permit issued on the altered or modified form and suhject the operator to cease and desist orders and civil penalties fi,r operating <br />without a permit pursuant to section 34-32.5-123, C R.S. <br />Signed and dated this ?h day of -J a 11 G( (?. Y t-i (.1; ? CJ <br />G'/) "I t If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />S1, g 11 C d: <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: President <br />Town/City/County Clerk <br />State of (_ o /6 ( cu U ) <br />ss. <br />Countyof it l al i) a ) <br />y s` <br />The foregoing instrument was acknowledged before me this l day of Cu '/ u a / L - <br />610,by ICi as prt,Iclcrl f off-A!S,2hta <br />4tary ublic; <br />r?. <br />%, . ?y My Commission expires: 1,211`5 <br />SIGNATURES MUST BE IN BITE 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