Laserfiche WebLink
WE <br />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 terns 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 detennined 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 fornn has been approved by the :'dined 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,fi;r operating <br />without a permit pursuant to section 34- 32.5 -123, C.R.S. <br />rA <br />Signed and dated this 3 day of F< rw u <br />d( d T f <br />Gd „str�� ,ate, T'►,r-. <br />Applicant/Operator or Company Name <br />Signed: <br />Title: .it C rG ra rr /'i-e asK -e r <br />State of —Jun t 4k n,•.._ ) <br />`� ) ss. <br />County of rig t'A ) <br />The foregoinA�j i trument was ac owledged before the this <br />2_015' , by fCoT I1 �.� t ✓- as -qc v. <br />If Corporation Attest (Seal) <br />Signed: <br />,Ie�u 7<� <br />Corporate Secretary or Equivalent <br />Town /City /County Clerk <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />You trust post sufficient Notices at the location of the proposed trine site to clearly identify the site as the location of a <br />