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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 ofthe 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 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 fording. <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 form 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 Material& 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, C R.S. 4. <br />Signed and dated this day of i?662-u ACA-1 <br />1 <br />frtZ 6Jc kVT- MM-&JVa" If Corporation Attest (Seal) <br />-Aa MAZZk_ Applic t/ perator or Company Name <br />0\tlllll//?? <br />if J/P <br />Signed: ; ?j0TA ?5igned: <br />Corporate Secretary or Equivalent <br />Title: Pik6Stiagr?1- <br />State of O d ) <br />ss. <br />County of ?. lLA2 W . ) <br />?N??. AUBLIG • 'QOM; <br />The foregoin instrument w s acknowledged before me this day of <br />ad/0 , by as _ 4-41 D6Q4 _000 <br />Town/City/County Clerk <br /> <br />? <br />My Commission expires: -1) ZZ <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