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<br />-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements <br />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, 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 sectlon 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modi(kadon 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 io secdo?? 34-32.5-123, C.RS <br />Signed and dated this day of A , Zu _ <br />S /? G +?3?t 4 ? c.S ? ?i ? i ?LnIG S ?' /C ?.L/ <br />Applicant/Operator or Company Name <br />Signed: G X2. <br />-- <br />Title: ?• P <br />If Corporation Attest (Seal) <br />?' . <br />Stgncd. Y <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />t <br />ate of } <br />St <br />) ss. <br />County of ?_?vCl.? - } <br />The foregoing instrument was acknowledged before me this day of <br />a %I ,F f? as !7. D-P t??yi ?1(Y? of <br />by Nri g !}7 cal Q <br />Notary Publics <br />My Commission expires:/) ZLZ 7, c <br />SIGNATURES MUST BE IN BLUE IN ` - <br />-f , _: '. -