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~- <br />Certi£cation: <br />As an authorized representative of the applicant, 1 hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence at the time <br />this application is filed, and located within 200 feet of the proposed affected area have been identif ed in this application <br />(Section 34-32.5-115(4)(e), C.R.SJ. <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 applicanUoperator, l do not have any extraction/exploration operations in the State ofColorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section I5-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-1 /1,CR.S., ojthe Colorado Land <br />Reclamation Act for the Extraction ojConstruction Materials. Any alteration or modification ojthis form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to secton 34-32-713, C.R.S. <br />Signed and dated this 3 day of ~-f~'"'~ "'°'°"" °2~~ <br />L, ~ , ~~~{~~, //SIC. <br />or Company <br />Title: I r~lic~'-vril~t <br />State of ~~/~~~D ) <br />f~ ) ss. <br />County of ' `K t' us ) <br />The f~~oing rostrum nt was acknowledged be <br />_, by 1~lG~l`G~ ~~7Pll~ as <br />If Corporation Attest (Seal) <br />me this 3 day of <br />Notary <br />My <br />Signed:~~--- ~~~c~~xt <br />Corporate Secretary or Equivalent <br />Mp Comrn'ssbn Exp6as Jan. <br />SIGNATURES MUST BE IN BLUE INK <br />Town/City/County Clerk <br />~l`b~ <br />M:~min~shareAvsfomisVCOnswc[ion 112,dw (0]l28@004) <br />