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-~- <br />Certification: <br />As an authoriz~drepresentative ofthe applicant, I hereby certify that the operation describedbas m~the of <br />the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permaneertman-made structure(s) in existence at the time this <br />application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 3432.5-115(4xe), C.RS.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 3432.5-115(4)(fj, C.R.S.; <br />3. As the applicant/operator, I do not have arty ex3raction/exploratien operations in the State of Colorado Y in <br />violation of the provisioms of tbe Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 3432.5-120, C.RS J as determined through a Board Ending. <br />4. I undeastand that statements in the application are being made under penalty ofperjury and that false state~rts made <br />herein are punishable as a Class 1 misdemeanor pursuant to Sectica 18-8-503, C.RS. <br />1'Iris form has been approved hY tGe Mated Land Reclamaliorr BoardpararrmR to serlimr 34-32.5-11Z,C.RS, of Nre Colorndo Land <br />Reclmnaaion Actfor the F.xfradion ofConsdndion M~er7aLr. Any operation or modifmmr'on of tlris javne shag resale ae voida-g nay <br />permittvaedon b}e ad4redor madrfindforwe andsrbjtdrhe operator to c+eafe anddesa?orders and aivrZparaIl'aaforapena'liard <br />a penny pwsamrt m section 332-123, GRS <br />Signed and dated this _____~_~ day of ~ ~„~~o.+ . .~©o <br />Benson Brothers <br />Applicant/Operator of Compaq N <br />~~~~~~ <br />Signed: <br />If Corporation Attest (Seat) <br />Signed: <br />Corporate Seeeetary or Equivalent <br />Title: Owners/Partners <br />Town/City/Cormty Clerk <br />State of Colorado ~ <br />ss. <br />County of Delta ) <br />t. <br />TTe fCoregoing instrument was aclmowledged before me this ~` day of ~~t, A'~e,nJ.ae. r -~~, by <br />dwc.r~ f15C~1 <br />7„~,uYi~ ~~nn 8S n, «ne r~~ ~ri.rt~" of . ~r~other~ <br />,,,,uuuir t~1 Jl ~ <br />_.nAELAN~!~~i,. ~.eDc r; <br />-••;` -•, Notary Public <br />~OTAR~; ; =_ <br />¢~'o- ~ = MyCammissionexpires: j(\-,~j_.JM7 <br />'°UBLIGr~ <br />.... P ~~ <br />,~Ofcot.OP~o~\SIGNATURES MOST BE IN BLUE INK <br />M~mmkhmetv~sY'.omtrrctim <br />