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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 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 IR Colora o La d'•4,. <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form sha11�i}estrlt i 'oiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil j mires for operating, ", \ <br />without a permit pursuant to section 34- 32.5 -123, C.R.S. ^I .)' q. <br />Signed and dated this day of a D // h <br />P "Gp <br />A a . 1 4 1 <br />If Corporation Attest (Seal) ' 4 ,. ° . <br />L.G. Everist, Incorporated <br />Applicant/Operator or Company Name <br />Title: Vice President <br />State of ) <br />) ss. <br />County of ✓ ) <br />-8- <br />day of <br />The foregoing instrument was acknowledged before me this <br />ad /I b Dennis L. Fields as Vice President <br />SIGNATURES MUST BE IN BLUE INK <br />Signed: // /ale& <br />Corporate Secretdry or Equivalent <br />Town/City /County Clerk <br />Notary Public <br />of L.G. Everist, Incorporated <br />My Commission expires: ZW/ 9 /ad /� <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 />