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Certification: <br />~ ~~~ ~~ <br />~ ~ ly `VZc,}a~t <br />,_ ~ <br />~ ~ a~ag l os <br />As an authorized representative of the applicant, I hereby certi.`y that the operation described has met t?+e minimum requirements of <br />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 this <br />application is filed, and located within 20D feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-115(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operations aze prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S.; - - <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 <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements made <br />herein aze punishable as a Class 1 misdemeanor pursuant to Section I8-8-503, C.RS. <br />This jorm bas been approved by the Mined Land Reclamation Board pursaarrt to sedion 34-32.5-111,GRS., ojthe Colorado Land <br />Reclamation Ad jot the Extradion ojGonstruction Materials. Any alteration or modifrcation ojthis jorm shall result in voiding any <br />permit issued on the altered or madifiedjorm and subject the operator to cease and desist orders and civil penaltiesjor operating wilJioat <br />a pesmit pursuant to section 34-32-113, SRS <br />Signed and dated this _~_ day of /`f~'~-~`~`'L~ a8 ~S <br />=T <br />ApplicanUOperator or <br />~~tt~~ oration Attest (Seal) <br />Name (..~~"' <br />rm cue. ~.rcr' ~' ~~,1-x~ <br />of (i~I~V~ZL+-U <br />~j ~ ) ss. <br />:y of / rt-O~l <br />was aclmowledged <br />I e as ~ <br />fps A~r~: ~ fnic.a v <br />`7 ~~''~~~~• ~''~ti orate Secretary or Equivalent <br />r <br />~, ..L <br />~~~T Town/City/County Clerk <br />~~ <br />forP,~.~g ~ ~ day of ,4.~.f~-(.C, ~0.~. by <br />of ,(~~ ~ ~ f ~ ~ <br />' .,y~~~ ~-,M.(~,It lbw t.{ <br />~~t~~ Notary Public /'~ ~dj ~ ~,,~ <br />, _,,: ~ • My Commission expires: "" /' . <br />BE IN BLUE INK <br />~um~ to~narzooa~ <br />