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-S - , <br /> Certification: <br /> As an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements <br /> of the fallowing 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 34-32.5-1 15(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,t 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. 1 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 I 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 34-32.5-112,C.RS.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of thisform 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 34-32.3-123,CRS. <br /> Signed and dated this day of 0��fetY bnr— <br /> If Corporation Attest(Seal) <br /> Applicant/Operator or Company Name <br /> 1 <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: C " Q�`'n tom" Town/City/County Clerk <br /> State of <br /> ss. <br /> County of R i o ____) p <br /> The foregoing instrument was acknowledged before me dus �S _day of <br /> of, rf La C1 c ye l,L.L.0 <br /> tc U <br /> Not ry Public <br /> '140TARy <br /> My Commission expires: <br /> "LiG :? <br /> '�. SIGNATURES..NfUiST B9 IN BLUE INK <br /> irj I:atwnlllMoa Fa�i�t Ja 4Z,2011 <br />