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-8- <br />Certification: <br />As an authorized representative Sf the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: I <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 of the proposed affected area have been identified in this application <br />(Section 34- 32.5- 115(4)(e), &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.; i <br />3. As the applicant/operat, <br />violation of the provisions <br />(Section 34- 32.5 -120, C.R.S <br />4. 1 understand that state <br />made herein are punishable <br />This form has been approved by the <br />Reclamation Act for the Extraction t <br />permit issued on the altered or mod <br />without a permit pursuant to section <br />Signed and dated this 3. d <br />Leone Sand and Gravel, LLC <br />Applicant/Operator or Company <br />Signed: <br />Title: <br />State of Lnibrad o <br />I do not have any extraction/exploration operations in the State of Colorado currently in <br />f the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />as determined through a Board finding. <br />mts in the application are beirig made under penalty of perjury and that false statements <br />a Class 1 misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />I <br />lined Land Reclamation Board pursuant to section 34- 32.5- 112,C.R.S., of the Colorado Land <br />Construction Materials. Any alteration or modification of this form shall result in voiding any <br />red form and subject the operator to cease and desist orders and civil penalties for operating <br />4- 32.5 -123, C.R.S. <br />day of !W ot4 " t , 02 C4 l 5 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />ss. <br />County of (Z YJi t'Yl Q S ) <br />The foregoing instrument was acknowledged before me this day of �^, i-ch . '7 O <br />,by Fra as Manager of Leone Sand and Gravel. LLC <br />a, Z-44222/�_ <br />Notary Public <br />My Commission expires: 0/b '?0 <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 />' I <br />