Laserfiche WebLink
-8 - <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 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 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)(1), C.R.S.; <br />3. As the applicantloperator, 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 3432.5-112,CRI, of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials Any alteration or modification of this form shallresult in voiding any <br />perink 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 seen 34-32.5-123, CR& <br />Signed and dated this 5 ~ day of a�5 <br />City of Fort Collins, a Colorado municipal corporation <br />Applicant/Operator or Company Name <br />rSt-41- <br />Title: <br />Signed: Jeff ih I' Deputy City Manager <br />State of Colorado <br />) ss. <br />County of Larimer <br />If Corporation Attest (Seal) <br />Corporate Secretary or Equivalent <br />Towr>/City/County Clerk <br />The foregoingent was acknowledged before me this ✓ day of lit/ `✓ <br />. by as <br />Deok <br />r; <br />AIMEE JENSEN <br />NOTARY PUBLIC Notary Ir <br />STATE OF COLORADO <br />NOTARY ID 19964022195 My Commission expires: i3 <br />MY COMMISSION EXPIRES JANUARY 13, 2017 <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 />