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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) 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), 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. 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 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 2-HTt+ day of / y o1t2.rt c.-6-e--r , 20 to <br />Applicant/Operator or Company Name <br />Signed: - -?--? <br />p ?rr3? <br />Title: 0.- <br />State of ro to ('ol.? ) <br />??'LGO ) <br />County of ?',l f o ss. <br />) <br />o24 (D, by ^-V1 (l , /(et- /ah as If Corporation Attest (Seal) <br />The f, in instrument as acknowledged before me <br /> <br />Signed: e_?? <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />? <br />yZ'AlJ day of ( 1)19 ?e-,"V4eP <br />0 <br />C r")c w CWL 4C9 L <br />otaty A. ' <br />BORCHARD ; l2 •l 13 <br />y Ninmission e . <br />ioR <br />{q '•........ <br />SIGNATURES MUST BE IN BLUE IOF COeO7 <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify th"tEe4eb4dion of a