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- x- <br /> Certification: <br /> As an authorized representati%e of the applicant, I hcreb% certiC, that the operation described has mct the minimum <br /> requirements of the follo«ing terns and conditions: <br /> 1. To the best of m- kno%%ledge.all significant,valuable and permanent man-made structurc(s)in existence at the time <br /> this application is filed,and located%%ithin 200 feet of the proposed affected area have been identified in this application <br /> (Section 34-32.5-1 15(4)(c).C.R.S.I. <br /> 2. No mining operation will be located on lands ssherc such operations arc prohibited b. laN% <br /> (Section 34-32.i-1150)(1).C.R.S.; <br /> 3. As the applicant/operator,t do not hay a am extraction/exploration operations in the State of Colorado current, in <br /> violation of the pro%isions 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 arc being made under penalty of perjure and that false statements <br /> made herein are punishable as a Class I misdemeanor pursuant to Section 18-8-iW_C.R.S. <br /> T his form has been approved by the Mined Land Reclamation Board pursuant it)section 34-32.5-112,C:R.,S.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Ann alteration or modification of this farm shall result in voiding inn <br /> permit issues(on the altered or nnidifred form and.subject the operator to cease and devi.st orders and civil penat}ies j,r operating <br /> without a permit pursuant to section 34-3z5-123,C:RS. <br /> Signed and dated this day of /Qy <br /> r <br /> z°A- If Corporation Attest(Seal) <br /> Applicant/Operator or Connpany Nannc <br /> Signed: Signc <br /> Corporate Scerctan or Equivalent <br /> Titic: �iit'ESsl�Eit�T Tm%n/City/Count% Clerk <br /> 7 <br /> State of L c 10 ) <br /> // )ss. <br /> Count. of Linz <br /> The foreg �oin . t Went ss ackno,.%led ged before me d 17 day of <br /> CA1�. b\ o Rom' as f <br /> ECAROL L 3titIC N( public <br /> NOTARY PUBLIC gqTg�E OFF COLORADO <br /> NOT <br /> 008717 <br /> SlOtr EWREe&WJ"1Z Wa <br /> ornmission expires �� 010/ <br /> SIGNATURES MUST BE IN BLtE INK <br /> You must post sufficicnt Notices at the location of the proposed mine site to clearly identit\ the site as the location of a <br />