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Certification: <br />- 8 - <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. 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 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 day of <br />q &rf 4 /E <br />Applicant/Opdrator or Company Name <br />Signed :A# / - „xri <br />State of Color Ca() ) <br />ss. <br />County of Mb t1 ro.6 c ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Title: Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this day of J h. Y�R G t <br />by rn a i Pa Pi as ( &f I curd— of <br />L 1 Oc <br />Notary-Public <br />My Commission expires: 1 1 bo 12 <br />SIGNATURES MUST BE IN BLUE INK <br />You must post :ices at the location of the proposed mine site to clearly identify the site as the location of a <br />