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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 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(4xf), 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 Boardpursuant to section 34-32.5-112,C.RS., of the Colorado Land <br />Reclamation Ad for the Daradion 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.RS <br />Signed and dated this 11 <br />Jack Clark, Jr. <br />day of January . 901 3 <br />Applicant/Operator or Company Name <br />Signed- <br />6'e1lz <br />Titl : Owner <br />State of &l o ra do <br />) ss. <br />County of <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />-A <br />The foregoing in tnunent w acknowledged before me this ! day of ?? u d <br />?Q L by C ? k .T? as cn(.f?CJ `?Y' of <br />- qy P. <br /> <br />DEBRA R. <br />PONCHAK <br />Notary Public , L l <br />My Commission expires: 7 / 0?104? <br />,N?ATU[iES MUST BE IN BLUE INK <br />You must post slii ent on of the proposed mine site to clearly identify the site as the location of a <br />My ommission ires 061