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l? <br />I <br />-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)(e), CJLS.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4xf), C.R.S.; <br />3. As the applicantloperator, I do not have any extraction/exploration operations in the State ofColorado 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 />This form has been approved by the Mined Land Reclamation Boardpursuant to section 3¢325-112,C.RS, of the Colorado Land <br />Reclamation Act for the Extraction ofConstruction Matedals Any alteration or modijkadon ofAlsform shall result in voiding any <br />permit issued on the altered or mod Jted form and subject the operator to cease and desist orders and d0fl penalties for operating <br />without a pernd(pursuant to section 34-325-123, GRS <br />Signed and dated this /9- 2` day of . rid /d <br />, h - A'1.' ao e-0.1, '+ / If Corporation Attest (Seal) <br />Applicant/Operator or Company 'Name <br />Al <br />7 <br />Signed: J !? !-r' f------ Signed: <br />' Corporate Secretary or Equivalent <br />Title Supervisor Town/City/County Clerk <br />State of Llp-a gAbo ) <br />) ss. <br />County of Rio 81-AdQ6 ) <br />The foregoing instrument was acknowledged before me this 1:3 A day of PiQ i L+ ; 91O 10 <br />. by PAd iI? P. lyioft AM as RoAb . tba --iP R. of k1 o ni-A CO <br />OTA ..o Pu 1c <br />r <br />Commission expires: 51 b 013 <br />SIGNATU E INK <br />You must post sufficient Notices at the location of the pi6Vd9aWne site to clearly identify the site as the location of a