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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met tile mininium <br />requirements of the following terns 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 orColorado 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 arc 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 pursnaut to section 34-31.5-112,C.R.S, of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this formn shall result in widin{ a7(Y <br />permit issued on the altered or modifred form and subject the operator to cease and desist orders and civil penalties for apertuing <br />ivithoat a permit pursuant to section 34-32.5-123, C.R.S. <br />A <br />Signed and dated this 2?- day of ,brv??y Zo 1/ <br />(J/dcat,<!c SW G?o?,?o, /rt+c. d 6G !/th i t? fovy,?,an? r3 <br />Applicant/Operator or Cot any Name O?lTl??, ? !y <br />Signed: <br />tARy <br />If Corporation Attest (Seal) <br />Title: r /GC t'/GSc?(eitt? Gtr, <br />`n+`'? A <br />State of ?1C t??t rX 0 ? <br />ss. °?'CO o 103 <br />County of -e,7? ) <br />Signed: <br />At loryt- <br />Corporate Sccr ry or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me th's 9VAi day of ??'??UC .` [ <br />,AO//,by Pe4fe .? . c as i c..C ?re5;cf n'? of WII Gmyw -T05. <br />d ha t(l?,?l ?Cl C-DNt?+r1 c P S <br />GSA C * k.t vrl y <br />71A , <br />Notary Public <br />My Commission expires: i; rt Ao6 <br />SIGNATURES MUST BE IN BLUE INK <br />You must post sufficient Notices at the location of the proposal mine site to clearly identify the site as the location of a