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~- <br />Certification: <br />As an authorized representative of the applicant, I 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 stmcture(s) in existence at the time <br />this application is filed, and located within 200 feet of the proposed affected azea have been identified 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 aze prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicant/opentor, 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 <br />(Section 34-32.5-120, C.R.S.) as detemuned through a Board finding. <br />4. I understand that statements in the application aze being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuam to Section 18-8-503, C.R,S. <br />This form has been approved by the Mined Land Rec/amation Board pursuant to section 34-325-IIl,CRS, ojthe Colorado Land <br />Reclamation Act jor the Fxbacgion ojConstruction Materials. Any aheration or modification ojthis jorm shall result in voiding any <br />pesmit issued on the altered or modtJted form and subject the operator to cease and desist orders and civil penalties jor operating <br />without a permit pursuant to section 34-31-I23, C.RS <br />Signed and dated this It O"~ day of ~,~G~~i& / ZQ~t <br />CQPtrvY~-1 ~COO~nb ~ Qrir~~. 'I~IaC, IUC_ <br />AoolicanUOoerator or Comoanv Name <br />Signed: <br />Title: <br />State of C~O~OPDr`~ ) <br />(~ ) ss. <br />county of \,~rtmt~ ) <br />The forego\ing instrument was acknowledged be <br />_, by ~1C~(1 ~. (~Q~I as <br />If Corporation Attest (Seal) <br />Signed: - <br />Corporate Secretary or Equivalent <br />this -~r1 ~ -day of <br />Town/City/County Clerk <br />~--•...~-Q,r <br />My Co , ~ ~ 0 s: ti~ <br />Commission expires <br />m:~mnW,aze~vxorms~conavuct;m i~z.a« (o~asrzooa~ <br />SIGNATURES MUST BE IN BLUE INK <br />