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0 Certification: <br />-8- <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 applicantloperator, l 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 fora: 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 penalties for operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this s day of A64%,s? ?o td <br />• / <br />Z aje_ If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Signed: Signe <br />Corporate Secretary or Equivalent . <br />Title: Vr e-_ 1 ".J t/?4% "?? At?9, Town/City/County Clerk <br />s I <br />State of L o/u? ci_a? iz, ) <br />nn_ ) ss. <br />County of ae ukdas on ) <br />The foregoin instrument was acknowledged before me this 5 Tit-- day of Aua Lt Si 070 / <br />by ?ono 6 /411+e_ ('.9-e12 as tMr U){'S of La4t?-Y?e cks!r - <br />I 1 214 aL.4-R <br />STENotary Public <br />0,J PR Y • y? My Commission expires: 3? ! 43/? <br />U G <br />: PU0?. <br />N? SIGNATURES MUST BE IN BLUE INK <br />You'foljls I "nt Notices at the location of the proposed mine site to clearly identify the site as the location of a <br />gNttn?NN?