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-8- <br />Certification: <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements <br />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 identified in this application <br />(Section 34-32.5-1 IS(4xe), C.RS.). <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 applicanUoperator, 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 determined through a Board fording. <br />4. I understand that statements in the application aze being made under penalty of perjury and that false statements <br />made herein aze punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This jorm has been approved by the Mined La»d Redamation Beard pursuant to section 34-325-111,C.RS, ojthe Colorado Land <br />Reclamation Act for the Extraction ojConslraction Materials Any alteration or modifkation ojthis jorm shall resuk in voiding any <br />perms issued on the altered or modified form and subject the operator to cease and desist orders and civil penaldes for operating <br />w&hout a permit pursuant to sedion 34-325-123, GRS <br />Signed and dated this C ~ day of , <br />~Psfei-~ ~:~1 i r~ e <br />ApplicantlOpetator or Company Name <br />Signed: ~ <br />Title: ~~b <br />State of ~~ L b'L rtS~Lty- ) <br />ss. <br />County of ~f~~~,O ) <br />[f Corporation Attest (Seal) <br />Signed- I /~1,~~,1~ ~~''2~~ <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />/~ <br />The foregojpg instrument was acknowledged before me this ,~? ~ ~ day of I,~%~r-LG~GI`- 2~ ~- n <br />~ ~~[, by ~' '(^; _ ~'~ ~ ~ .~=(. as ~ % t of l ~~ ~~ 9~r,' ;~,cZ„vC y~r^.. <br />:/ <br />,ff <br />.~p.RY p~. ~ ~A 'L~. ~~~~ ~L~ <br />6 Notary Public <br />TERRI My Commission expires: ~'~i~7' ~ j <br />TRUJILLO ; ~ / G`~ ~7~ <br />9•• ~ ~ SIGNATURES MUST BE IN BLUE INK / <br />M:Ymn~shaa~nr ~i(L9~irJigyl7~,tliPMuved OS/I Il2005) <br />