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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) 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 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 0 -74 day of ?jMVCsry 20// <br />O/W60-/lc SW 6"o% /.7c. d 6G 61/9 i ?a! "C5 <br />Applicant/Operator or Co any Name O?l?'IeSw ?cr?it /cf <br />Signed: ?--. - 0 , 1-1? - -1/ <br />0. AA ?kl i. <br />Title: P Clchy1-L <br />fee /L5? (.A State of O ss. County of <br />If Corporation Attest (Seal) <br />01 <br />Signed: <br />Corporate Seca ry or f quivalent <br />Town/City/County Clerk <br />The foregoinA} instrument was acknowledged before me th's 2W1 day of ke6?uet ? <br />o? 0 rl , by I'eP t' \J, as i [? ?f f S iG?i° YI? of %,g TA c. <br />0(AQ Ulm <br />es a ,o u ?( y <br />Notary Public <br />My Commission expires: <br />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