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Certification: <br />Applicant/Operator or Company Name <br />Signed: . e <br />Title: ?�� <br />The foregoi1�n1�g instrument <br />c& �� by T TDU:fa <br />rd <br />State of CAC O•Ci C> ) <br />) ss. <br />County of y Li Y10._ ) <br />X <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. 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,C1.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 />was acknowledged before me this (cA day of <br />mel�n r n r■ as aYVI 111 y tUr cimc n of \I t.), Cn<<.v &I <br />Voi <br />ty"v y�N, •\ Qy.{O <br />-. <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />Public <br />My Commission expires: 7 /6 - <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 />