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i Ma , . -. <br />-~- <br />an authorized representative of the applicant, I hereby ~Y that the operation describedhas metthe mininnmrrequirements of <br />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 200 feet of the proposed affected area have been idertified in this application <br />(Section 3432.5-115(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), C.RS.; - <br />3. As the applicant/operator, I do not have auy extracfion/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 3432.5-120, C.RS.) 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 made <br />herein are punishable as a Class 1 m;~Pn,r~^or pursuant to Section 18-8-503, C.RS. <br />' This form has been approved by the Mored Land Reclamation Board puraumrt to section 3¢32.5-IIZ,GRS, ojthe Colorado Land <br />Reclamation Actjor the F.xbaclion of Construcion Materials. Any adterotion or morfifierRion ojthi<jorm shaQtesult in voiding any <br />permit issued on the altered or modifiedjorm and subject the operator to cease and desistorders and eivilpenalties joropemlbrgxdlrout <br />a permit punuaruW section 34-32-I23, GRS <br />d <br />Signed and dated this Z h' day of t`nofe~n .200 5 <br />O\~c~s-~\~e S W Cirou.P ,Yule . <br />Applicam/Operator or Compaq Name <br />Signed: <br />Title: V i o P~vs,c~e/t7~ <br />State of ~,d~rrr[Lac~ <br />ss. <br />Cou~y of Y`n e 5 n 1 <br />Town/City/Cou~riy Clerk <br />The foregoing;nstnmtearwns acimowledged before me this 'L~~ day of mav~lti ao°s°S - by <br />Cta.ia t_arr.her~~a as Vice ~res•.~e,r,'t of O\acas-.-\~e S~~ C~ .o v, <br />.~ <br />ff Corporatia~n Attest (Seal) ~ :,a <br />_ y~_ <br />Signed: '`lA-' ~"~ <br />Corporate Secretary or Equivalent <br />Notary Public <br />My Commission expires: 3 •Z9 •07 <br />SIGNATURES MUST BE IN BLUE INK <br />(a'+ne~) <br />