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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)(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 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 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 Materials. Any alteration or modification of this form shall result in voiding any <br />t?or operating .. <br />permit issued on the altered or modifted form and subject the operator to cease and desist orders and civil penalties <br />without a permit pursuant to section 34-32.5-123, C.R.S. `? r' <br />,f 4' <br />Signed and dated this ?- day of d' ?nry ?r^?l r , : wt C J U -J, <br />UJ 14 0'/y co If Corporation Attest (Sear <br />Applicant/Operator or Company Name Cu o <br />Signed: Signed: <br />Corporate Secretary or Equivalent <br />Title: Road Supervisor District 2 Town/City/County Clerk <br />) <br />State of CrAGrodC) <br />) ss. <br />County of x) 3 i i?t tl1 ) <br />The foregoing instrument was acknowledged before me this? day of <br />aU by ° S Sr° V <S k d sc as Di t • , ",A of I_k)()'JAj0dj]Q,1 <br />(-c? L-tf?+ <br />. .,.1,F Notary Public <br />s ?_r My Commission expires: <br />= 'F SIGNATURES MUST BE IN BLUE INK <br />Ya ? t bost`sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a <br />9`