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-~- <br />CertiScation: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the follovaing terms and conditions: <br />1. To the best of my latrnvledge; all significant, valuable and permanent man-made structure(s) in evstence at the time <br />this application is filed, and located within 200 feet of the proposed affected area hm+e been identified in this application <br />(Section 34-32.5-115(4){e), C.RS.). <br />2. No ruining operaton x+ill be located on l:mds where such operations are prohibited Ir.' lax- (Section <br />3d-32.5-115(4)(f); C.RS.; <br />3. As the applicanUoperator, 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.RS.) as determined tluough a Board fmding. <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.RS. <br />Signed an ated this is _ day of ~~ _~00~- ,t••'•~ e ^ Y ~," ~-. <br />~ If Corporation Attest (Seal) '- (_, %-., <br />ApplicantlOperator or Company Name , : ^. <br />Sign Signed: -r~~~! ~.~! ~~ <br />Title: ~`~~ S~ r~ e L7 <br />State of ~UIUtrRd O 1 <br />Corporate Secretary or Equivalent <br />Town/CitylCounty Clerk <br />I^n ) ss <br />County of ~ ,° SR, ) <br />The f g instntment was aclmawledged befor me th/is ~°~ ~ day of S aG0 or? <br />by ~~~ ~ ~~~ as ~1'CSitl~ytrt of ~1 ['ov1Sf/vtCfl~~'l,~1-C, <br />Notary Public <br />~;,.~,., <br />My Commission expires: ' ~.~ .~ <br />._, f,. <br />~~- ~ ~y C '•. ~~.:. <br />SIGNATURES MUST BEINBLUEINK = "c (v~~ 1.~~~ :`~ i <br />M:~~sLmWffomsu~nosaactiw uxm< <~aurzoup ~~°' <br />L~ n•. b~~o ~`` <br />