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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 ofmy 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 arca 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 pei jury 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 dais form shall result in voiding any <br />permit issued on d►e altered or modified form and subject the operator lo cease and desist orders and civil penalties Jim operating <br />without a permit pursuant to section 34- 32.5 -123, C.R.S. <br />Signed and dated this day of <br />D /durst /c S WGrwp � //lc <br />dba- (i4d C49)-46 /as9 <br />Applicant/Operator or Coi 1pany Name <br />Signed: <br />Title: Vice <br />ice �%erS /66.;v./ <br />State of 2D 1DrZdb ) <br />) ss. <br />County of `( ) 4 <br />The foregoing in rument was acknowledged before me this, 3 day of / e/ <br />o? On , by i - S:E iii(.1 as V,`,,a° 1ple5 :4 of af SW 6 tc <br />�J alga: UVheI &owpee: <5 <br />\ , , e9„,E„, A <br />- 8 - <br />SIGNATURES MUST BE IN BLUE INK <br />, 20 // . <br />If Corporation Attest (Seal) <br />Signed: �1 /�tl / / r / <br />Corporate Secrete''' or Equivalent <br />Town /City /County Clerk <br />Notary Public /J <br />My Commission expires: 4 o�DI� <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a <br />