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f~ <br />•8- <br />CertlflCatlOO: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of <br />the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made shucture(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 34-32.5-115(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 arty extractionlexploration 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 34-32.5-120, C.RS.) as determined through a Boazd 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 misdemeanor pursuant to Section 18-8-503, C.RS. <br />Tkis form kas been approved 6y the Mined Land Reclamation Board pursuant to section 34-32.5-11 Z,GRS, ojrhe Colorado Land <br />Reclamation Ad jot flee Extraction ojConstrudion Materials. Any alteration or modification ojtkis form shall result in voiding any <br />permit issued on Oee aHered or modifredjorm and subject the operator to cease and desist orders and civi[pena!liesjor operaL'vrgwCleout <br />a permit pursuant to section 34-32.5-123, C.RS <br />Signed and dated this j~q t~ day of / V t7 / C "~ ~l ~ ~. <br />_Qt~C_4,5}~~ Slll GrowPn_J--nC._ <br />d6a (/t.,ni+e~ Como~.v~te: nt mPro l.okn~-~ <br />Apphcant/Operator or Company Name <br />Signed: <br />Title: t~ceS~(~ev~~ <br />If Corporation Attest (Seal) <br />Signed• ~~ <br />Corporate S tary or Equivalent <br />State of ~ o\uro, ao <br />Town/City/County Clerk <br />ss. <br />County of YhP.S0. 1 <br />ti <br />The foregoing instnlment was aclmowledged before me this + lob' day of N one mbe f Z o0 5 , <br />by ClfAi_e ~ Qyt.bt~c-~ as of o ~ c~ c ns•4~r S ~ Cocn~.~.Sylc . <br />~,~ P , Uc aha•. tf.m~.a-e d. Can(w.YVrs of si4oa ea..~ <br />OP• •• g~E ' :O M..3.A...a 1A~.aa.wn~ <br />Z: ~~PJ~a j~ Notary Public <br />s,~ <br />,~:, :.;~~ My Commission expires: 3-24 •o~ <br />MUST BE IN BLUE INK <br />I <br />MUninWwelvsfotm+\Cmatruction 112.doc (Approved 03/11/2005) <br />