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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 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 l day of O( ;'W , 7- I Z . <br />Applicant/Operator or Company Name <br />Signed / __ Signed: <br />Title: th 4, ikPrP�,Q <br />State of CntOr .p <br />) ss. <br />County of rUj E f ) <br />The foregoing instrument was acknowledged before me this I5 day of (" - )C.. _ q.9_ ac i )., <br />, by fr∎ L \ -f as Mct"44,, of USL/ 11 r u 51- LLC <br />ot. • N O •� <br />■ c' . • T • .: j Public <br />= • �4 �e o M <br />D '• L '"( 1ct Commission expires: <br />SIGNATURES 1/ M)�E INK <br />1/ 1911111b <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 />- 8 - <br />If Corporation Attest (Seal) <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />1ki 31 201lp <br />