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-8- <br /> j <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 /> I. To thc best of my knowledge,all significant,valuable and permanent man-made structurc(s)in cxistcncc at thc 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 arc prohibited by law <br /> (Section 34-32.5-I l5(4)(f),C.R.S.; <br /> 3. As thc 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 I misdemeanor pursuant to Section 18-8-503,C.R.S. <br /> Illlff, <br /> This form has been approved by the Mined Land Redamation Board pursuant to section 34-32.5-112,C.R.O b a ..,i/ nd <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form) .I''4 - .'. . R/l' <br /> • <br /> permit issued on the altered or modified form and subject the operator to cease and desist orders an4.' or? ratio <br /> without a permit pursuant to section 34-32.5-123.CR.S. • 40 <br /> • <br /> 11!f _� f\ . <br /> Signed and dated this l lcC� day of 1 , a . Ice • <br /> _ • <br /> IV t it .a. <br /> Connell Res rceS,�nC. ., <br /> If Corporation Attest'fS O'•••••••• •`.,4 <br /> 4. <br /> Applicant/Op rator or mpany Namc It a • <br /> - //11111‘‘` <br /> Signed: Signed: << P <br /> Corporate Secretary or Equivalent <br /> Title: President Town/City/County Clerk <br /> n <br /> State of ( �� CV Ci ) <br /> )ss. <br /> County of C ) <br /> The forescing instrument was acknowledged before m is day of <br /> W.,\0(1. VI KA. A)QX C CI as p-"e( .�1 6�'L of� G`Y 1 rCE <br /> ,. 1 1, f ad <br /> JENNIFER LINDBLAD \_ )JIULli <br /> (?-�` ` �ii�A i <br /> Notary Public Notary Publi` <br /> State of Colorado <br /> Notary ID N 20144008302 ,_,'-\ (;-0 <br /> My Commission Expires 02-21.2026 My Commission expires: L)-'L 4 .1- <br /> SIGNATURES MUST BE IN BLUE INK <br />