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<br />- ~ - <br />• Certification: <br /> <br />As an authorized representative of the applicant, f 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) in existence 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 I5(4)(e), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law (Section <br />34-32.5-1 I5(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 (Section <br />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 />51- <br />Signed and dated this <br />• M~A• C~oNGIz~TE <br />day of ~~AIZ~1 , 20o O <br />ApplicandOperator or Company Name <br />I <br />Signed: i <br />Title: 1QT 2S i ~n i< <br />State of l.~~ORt~C~C'~ ) <br />) SS <br />County of ~~~~~ ) <br />If Corporation Attest (Seal) <br />Signed: 0. <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged ~ me thils day of <br />by mfl(~.'~61~ A~C'Fll"fRUA as __ PStcle.')~ of 111. A. oncrete onStru-dicr~~~n~~ <br />,. <br />No\\~~_99'' Public <br />My Commission expires: lU - I /-ADO J <br />SIGNATURES MUST BE IN BLUE INK <br />M:UQMSHARE\V$FORMSVH27COII APP OLIOl9o <br />