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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, 1 do not have any extraction /exploration operations in the State of Colorado currently in <br />violat on`of "thc prove "s �iis oft Colorado 'L and Re TaTniation A`ct for the Extraction of Construction ivlaterials <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 /"7' day of <br />. -o-gJ 1 a <br />mpany Name <br />- 8 - <br />n Attest (Seal) <br />Signed: j' <br />Title: /f e <br />(LLJJL � rr Let <br />State of (760 ) <br />ss. <br />County of LA J ) <br />The foregoing instrument was acknowledged before me this day of > 112_,La ,c _ , <br />as it A C7ki -- d`6 lA.f� of 6 6 <br />020/1 ,by <br />SIGNATURES MUST BE IN BLUE INK <br />Corporate re to o Equivalent <br />q u ivalent <br />To n/City /County Clerk <br />.14 Al <br />. 'u• is <br />My Commission expires: <br />/ -,3% -/5 <br />I LO tf-el <br />