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~- <br />Certification: <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements ofthe <br />following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 34-32.5-110(1)(a)(VIII). <br />2. To [he 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 identified in this application <br />(Section 34-32.5-115(4)(e), C.R.S.). (NOTE: For 1 IO operations, the affected area includes al] lands delineated by the permit <br />boundary.) <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-1 l5(4)(f), <br />C.R.S.). <br />4. As the applicant operator, I donot have any mining/exploration operations in [he Stale of Colorado currently in violation of <br />the provisions ofthe Colorado Land Rectamation Act for the Extraction ofCons[tuction Materials (Secfion 34-32.5-I20, C.R.SJ. <br />5. I understand that statements in the application aze being made under penalty ofperjury and that false statements made herein <br />are punishable as a Class 1 misdemeanor pursuant [o Section 18-8-503, C.R.S. 1984. <br />This form has been approved by tl+e Mined Land Reclamation Board pursuantta section 34-32.5-110,C.R.S, ojthe Colorado Land <br />ReclamationActjortheExlractionojConstructionMaterials. Any alteration ormodificaNonojthisjormshallresultinvoidingany <br />permit issued on the altered or modified jgrm and subject the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant to section 34-32.5-723, GR.S. <br />Signed and dated this __~"~ day of ~ ,~~ <br />State of CP.AC~~f(;(~l7 ) <br />1~ n )ss. <br />County of ri\~' l Q C~DI'~ ) <br />.~ 1. <br />The foregoing instrument was acknowledg <br />-7' by 'Sdn~n to ~\c\nD~S <br />~. ~ A~2-5 OoJ ~ u 1-~Z~ <br />M:\minlsAare\vsfonns\Cons[ruc[ion110 (Approved OS <br />If Corporation Attest (Seal) <br />~+puoun.., / <br />a" PSCSnU~~ <br />~' 'l°q~ [e Secretary or Equivalent <br />«r ''~~ ='f~wt/Gi County Clerk <br />* ~ SEAL *~ <br />