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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 Boardpursuant 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 3 r� day of ft k I'M a e% , 2 Q( 5� <br />/.d fd ff- Gd „3riKC , oh, �NG . <br />Applicant /Operator or Company Name <br />Signed: <br />_/�� uA__� <br />Title: is C ' e l`a r�/ �'i -e q'T., <br />T_ <br />State of v► c 4k " LA_ ) <br />ss. <br />County of <br />T he foregoin i tru ent was ac owledged before me 'this <br />, by C' ' � t as Scc v <br />. Z I S � <br />If Corporation Attest (Seal) <br />Signed: %� <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />Q� <br />—�� day of r,t r'va” <br />/ I /c..Sv- --- _ of Lo � Ce�.S'j��c'Y •, <br />nu <br />OFFICIAL SEAL w <br />MICHAEL S HOWS <br />6 NOTARY PUBLIC • INDIANA <br />O > ALLEN COUNTY <br />C0f"m• Nov 18, 2021 <br />SIGNATURES MUST BE IN BLUE INK <br />ry <br />Nota <br />Public <br />My Commission expires: <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 />