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-8- <br />Certification: <br />As an authorized representative of the applicant, 1 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) inexistence at the time <br />this application is filed, and located within 200 feet ofthe proposed affected area have been identified in this application <br />(Section 34- 32.5- 115(4)(e), C.R.S.). <br />2. No n-dning 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 Actfor 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 + "- 7sl 3 <br />/7,9 19' <br />�C/1 V'6 _ r?/ C- If Corporation Attest (Seal) <br />Applicant/Opera)nfor Con)o ny Name <br />Signed: <br />Title: Owner <br />State of (1-Zc as c, ) <br />) ss. <br />County of ekz6 4 <- ) <br />The foregoing instrument was acknowledged before me this <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />2- /2 day of - Z e <br />'a e f of ;R "/ C120( Jrr�Lrl -� <br />Not [ry Pub}i�c NUALL U. SCHAFER <br />NOT ARY PUBLIC <br />STATE OF COLORADO <br />My mm1�K�;'WVitD1995401606, <br />Y COMMISSION EXPIRES 12/06/2016 <br />SIGNATURES MUST BE IN BLUE INK <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 />