Laserfiche WebLink
-8 - <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the <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 1he 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 <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 c <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction <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 <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 34-31.5-112,C.R.S., of the Cola <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in vi <br />permit issued on the altered or modifred form and subject the operator to cease and desist orders and civil penalties for <br />without a permlt pursuant to section 34-32.5-123, C.R.S. <br />f <br />Signed and dated this day of , as <br />Applic'aant/Operator or Company Name <br />Signed: <br />Title: president <br />State of Cf.) ) <br />If Corporation Attest (S al) <br />Signe <br />Corporate Secretary -or <br />) ss. <br />County of <br />The foregoing instrument v as acknowle ged before me this day of <br />1 , by as of <br />r� A <br />law <br />in <br />Land <br />g any <br />Town/C-ity/CQun Olerk <br />CA Q�J ► K -f L!u <br />SHERRI RENAE BIRD Notary Public <br />Notary Public - Stab 01 Colorado <br />Notary 10 20164024076 <br />My Commission Expires ,fun 24, 2020 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 />