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Fe13 10 '1 1 *11 O3,a <br />-8- <br />Certification: <br />P. I <br />As an authorized representative of the applicant, I Hereby certify that the operation described has met the minimum <br />reguirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made structare(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 3432.5-1 l5(4xf), C.R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State of Co lorado 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 I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has beea approved by the Mbied Land Reclamation Board pursuam to sectlar 34-325-112,0 R&, of the Colorado Land <br />Reclamation Act for the Zdrac don of Cons&uctlon Materials. Any iWeradon or modifkatlon of thh form shat! result in voiding any <br />permit issued on the altered or modified form wad subject the operafor to cease and desist orden and civil yenallles for operadag <br />without a pem*pursuant to section 34-32.5-123, GRS <br />Y4L <br />Signed and dated this /L) day of 611 <br />W 4UA-- d,6FL7=P- (IM PA y If Corporation Attest (Seal) <br />Applicant(Operator or Company Name <br />Sigoed: ?----- Sign <br />Como a Secretary or Equivalent <br />Titie: Town/City/County Clerk <br />State of &L-61Z41>0 <br />?BEN y )Ss. <br />Countyof_ Pre <br />The foregoing instniment was acknowledged before me this l day of 5 b <br />ZOf!_ by as of <br />= <c.? 0 : O Notary Pub <br />• •4('., My Commission expires: 0 0/=/( <br />?1.; SIGNATURES MUST BE IN BLUE INK <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a