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~;~.1 ;,L l~l,~i <br />- 8 - Division u... _. ,~,~„on, <br />Mining and Safety <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirercents <br />of the following terms and conditions: <br />I. To the best of my Imowledge, all significant, valuable and permanent man-made structure(s) inexistence at the time <br />this application is filed, and located within 2tM1 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-115(4xe}, C.R.S.). <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.R.S.; <br />3. As the applicant/operator, I donor have any extraction/explomdon operations in the State otColorado currently in <br />violation of the provisions of the Colorado band Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as detemrined through a Board finding. <br />4. I understand that statements in the application are being rrmde under penalty of perjury and that false statements <br />made herein are punishable as a Class i misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Tbis form has been approved b1'the Mined Land Redametion Board pursuon[ to section 34-32.5-112,C.2S, ojUre Colorado Land <br />Reclamation Act for the Eshacllon of Construction Materials Any aNeration or modijlcatlon aJthis farm shall resuiY in voidtng any <br />permit issued oa thr altered or modiJred form and subject tke operator to cease aad desist orders an4 rivll penah9es jor opereling <br />without a permie pursuant to section 34-32.5-123, GR.S <br />Signed and dated this _~'.. __ day of it/DI/i°/77~~Y , ~_: - <br />LOUe j~'~~~'-~7G'~ ~T~'i• <br />App]icanUOperator or Compare Narric <br />Sign <br />Title: V [J ~.r'A ~-r i3-,C~ C <br />State of C~~D~~p~ ) <br />County of ~1~ ~l TY1~.~ ) <br />If Corporation <br />Signed: <br />The foregoing instrument was acknowledged before me this _.__~ day of _.LU ~ u <br />by '$Q.AD ~A~~ as ~(~_~ _ J of <br />- J~ ~ <br />f-.-- r _.. ~__ - <br />ta }\~ y I:. ~~.~ <br />Notary blic <br />yG,~pTFt~~s'~ <br />My Commission expires: ~ ~ LI ~p~~l' <br />~, ,p_ ~, ; fly SIGNATURES MUST BE IN BLUE INK <br />S `hrw as taavrovea osn moos) <br />~ o¢ roLO~ ~~ <br />,~: <br />Y~ItI-Yi'-~-t'4•~r'.' <br />Town/City/County Clerk <br />