REV04073

• Permit No: M1978225L
• IBM Index Class Name: Revision
• Doc Date: 6/18/2001
• Doc Name: CONSTRUCTION MATERIALS REGULAR 112 OPERATION RECLAMATION PERMIT APPLICATION FORM
• Type & Sequence: CN1
• Media Type: D
• Archive: No

Certfication:

As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements
of the following terms and conditions:
1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in eeistence at the tirne this
application is filed, and located within 200 feet oC the proposed aH'ected azea have beer[ identified in this application
(Section 34-32.5-I IS(4)(e), C.RS.).
2. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-f IS(4)(f),
C.RS.;
3. As the applicant/operator, [ do not have any extraction exploration operations in the State of Colorado currently in
violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section
34-32.5-120, C.R.S.) as determined through a Boazd finding.
4. I understand that statements in the application are being made under penalty of perjury and that false statements made
herein aze punishable as a Class l misdemeanor pursuant to Section 18-8-503, C.RS.
Signed dad dated this ,~~ day of ~ jk~ ,Zan t
TROY CRANE. BACA COUNTY COMMISSIONER DISTRICT III
ApplicandOperator or Company Name
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Signed: / .,.~.
Title: BACA COUNTY COMMISSIONER DISTRICT III
State of _ Colorado )
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County of Baca )
If Corporation Attest (Seal)
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Signed: ~ ~10 . ~ .y < n~ ~.r L -
Corporate Secretary or Equivalent
Town/City/County Clerk
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he foregoing instrument was acknowledged before me this day of ~J~E ,~ ~ ~ ,
by TROY CRANE as COMMISSIONER o ACA COUNTY DISTRICT rII
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Notary Public
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SIGNATURES MUST BE IN BLUE INK ~
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