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(4xe), 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 Mowed Land Reclamation Board pursuant to section 34-3Z.S-112,CRS, of the Colorado Land <br />Reclamation Act for the Extraction of Consftedon Materials Any alteration or modifweadon ofthisform shag result in voiding any <br />permit issued on the altered or modfied form and subject the operator to cease and desist orders and civil pena&W for operating <br />without a permit pursuant to se n 34-32.5423, C-R& <br />Signed and dated this .— day of .2a/s— <br />City of Fort Collins, a Colorado municipal corporation <br />Applicant/Operator or Company Name <br />y�F FORrc <br />Signed: <br />Jeff St <br />Title: Deputy City Manager <br />State of Colorado <br />County of Larimer ss. <br />If Corporation Attest (Seal) <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing nt was acknowledged before We this ✓ day of <br />by as 5 <br />. <br />AllkkE <br />.-'C <br />OVS.NEU3UENC Notary yli <br />- tPa <br />STATEDF 'y ` DSO <br />�� . - <br />NO ARY lb 964022195 My Commission expires: ( i <br />INY COIYIMI,�SSi.ON F.t(P ES <br />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 />