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<br />~I <br />~- <br />- Certification: <br />As an authonzed rcpresentauve of the applicant, I hereby certiC,~ that the operation described has met the minimum requvements <br />of the following terms and conditions: <br />I . To the best of my knowledge, all significant, valuable and pennanent 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 34-32.5-11~(4)(e), C.RS.). <br />2. No n>ining operation will be located on lands where such operations are prohibited bylaw (Section 34-32.x-11~(4)(f), <br />C.RS.; <br />3. As the applicant/operator, I do not have any extraction 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 (Section <br />34-32.5-120, C.R.S.) as determined though a Boazd fmding. <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 I8-8-503, C.RS. .. <br />Signed and dated this ~ day of <br />~~ <br />Applicant/ Aerator or Company Name <br />Signed: ~~/L~ CZ2/~-r/F~- <br />Sigted: <br />Corporate Secretary or Equivalent <br />Title: Q u/ ~/ B ~ ~-- <br />State of CoLdRktllO ) <br />ss <br />coutttyof ~~5 AN+rnks > <br />01~0~ . <br />If Corporation Attest (Seal) <br />Town/City/Cotmty Clerk <br />The foregoing instrument was acknowledged before me this ~ day of Ja ~.-r ~~~ , <br />by X12 ty-)vT Q . `ri4erl,R i~R cl.~~s f)aryFiR of J Rr+Rof~~C ~R gy6G <br />_ i. t~ <br />_ _ _ _ .~ Not Public <br />-~ <br />~.'- '' • 1_= ~~ My Commission expires: 1 ~'0%~OpZ. <br />-i~-"-...,.--- <br />SIGNATURES MUST BE IN BLUE INK <br />M:~~e.r~.,r~.~zrzrcoizner ro~inn_ooo> <br />