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_g. <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation describedhas met lheminimmnreq~riraneots of <br />the follow~g terms and conditions: <br />1. To the best of my knowlodge, all significant, valuable and permanent man-made stnrchnr.(s) in existence at the tune 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 prohrbited by law <br />(Section 34-32.5-1i5(4)(f), C.RS.; <br />3. As the applicant/operator, I do not have any extraction/cxploration operations in the State of Colorado eanrently in <br />violation of the provisions of th6 Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.RS.) as through a Board Ending. <br />4. Itnndastaad that statements in the application are beingmade 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 />17eis form has beew approved by tke Mined Land Reclamation Board pursuant fo setTion 34-3Z.5-II1,C.2S, of flee Colorado Land <br />Redmna7ionAdfor the Fxbaerion erf CoxttrucYime MattriaLt. Any alteration or modification of this form shaQresult in voieGng any <br />permitisseeed on tree aHered or moe&jud form andsubjedrhe operaWr m cease and eksist orders and avilpenaHiesfor oparrmrgxdhord <br />a pmeeitprrrsumd to section 3¢32.~I23, C.RS <br />Signed and dated this ~ day of T ~`! <br />C <br />Applican for or Caarpany Name <br />Signed: ~ d~[~cJ <br />Title: c5e C ~~~/ ll <br />State Of ~ Wr>Jp ) <br />) SS. <br />County of ~.~~ ) <br />The foregoing inctnm+cnr was aclmowledged <br />by .~h~.:~, a ~ , as <br />s ;' lyOTAgy ,. <br />~`•. pUgLIG - <br />/ ~ ~\\ <br />, lF~ ~~p, <br />'~o~n~~~~~^iua~ <br />--~ ~ `_-' <br />Notary Public <br />My Commission expires: o~. ~zsl 10o r <br />SIGNATURES MUST BE IN BLUE INK <br />if Corporation Attest(Se~l)~ ~ ~~ ~ i <br />Signed: <br />Secretary ~ Equi <br />Town/City/Cbimty Clerk <br />before me this <br />i ~"~ day of don s <br />LL <br />SYt./L1./ Of t . t.,.A tYwf/ ~elhC~tl A _1M1C. <br /> <br />hr:~~~r~.~v~e~ rraaa (Aprrovea osnrnoos) <br />