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Certification: <br />As an authorized representative <br />requirements of the following ter <br />-8 - <br />the applicant, I hereby certify that the operation described has met the minimum <br />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 of the proposed affected area have been identified in this application <br />(Section 34-32.5-115(4)(e), C.R.S.). <br />' I <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 applicantloperat <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 <br />I <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 />nts in the application are being made under penalty of perjury and that false statements <br />a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <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 thisform shall result in voiding any <br />ed form and subject the operator to cease and desist orders and civil penalties for operating <br />1-32.5-123, C.R.S. <br />day of 9-06" <br />Leone Sand and Gravel, LLC <br />Applicant/Operator or Company (Name <br />If Corporation Attest (Seal) <br />Signed: `?K off'": " Signed: <br />Corporate Secretary or Equivalent <br />Title: Manager Town/City/County Clerk <br />State of Ldlbrad o 1 <br />4 <br />County of 4aj mQ5 ss.) � <br />The foregoing instrument was acknowledged before me this day of YYI^, rrt h _ ,70 ) `J , <br />by Fra as Manager of Leone Sand and Gravel, <br />_LLC <br />XCT Ta <br />To I� Notary Public <br />S •' 1 <br />� � + My Commission expires: <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 />