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-8- <br />• Certification: <br />As an authorized representative of the applicant, 1 hereby certify that the operation described has met the minimum <br />requirements of the following tenns 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 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, 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 form has been approved by the Mined Land Reclamation Board pursuant to section 34-325-112,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 _ day of <br />.Goose Haven Reservoir #2 - Complex Expans <br />"A <br />Applicant/Operator or Company Name <br />Signed: %G <br />Title: <br />t„ <br />State of <br />ss. <br />County of 2nA&14n1 ) <br />Corporation Attest (Seal) <br />\J\FA?'?? TF <br />RULE • Si <br />5 •o <br />t ? <br />4 <br />06 0 <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this day of C)U'? ? <br />CDby as ?of <br />??- <br />' BA!4 Notary Public <br />a0 Ap', <br />My Commission expires: >I I <br />t <br />• , ?NATURE5 BE IN BLUE INK <br />You must post sufficient Notices at the' a^(ion , osed mine site to clearly identify the site as the location of a