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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 tiled, 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 arc 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 I 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 />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penaltiesJor operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. ^ <br />Signed and dated this l day of -UL__ , Z l/ ?. <br />? vn S , <br />Applicant/Operator or ompany ame <br />Signed: <br />Title: President <br />State of &Ls=a? <br />) ss. <br />County of 1A ) <br />If Corporation Attest (S&" <br />Signed: <br />Co orate ecrctary or Equivalent <br />Town/City/County Clerk <br />The foregoin i strum1en-t /was acknowledged before me this /off day of --? <br />o?D/Lj , by f Js ?a` ?'1 1- ?Q r1-c?, as ?r ?nf of <br />Notary Public / <br />My Commission expires: d <br />SIGNATURES MUST BE IN BLUE INK -' _- _ <br />`b a <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as cation of. ' - `