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<br />-~- <br />Certification: <br />yn-l4g8-olaCZ) <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of <br />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 this <br />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.RS.). <br />2. No Honing operation will be located on lands where such operations aze prohibited by law <br />(Section 34-32.5-115(4)0, C.R.S.; <br />3. As the applicant/operator, 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 />- ~~z,~--~4-32-3-1-2Es-R~:)~-dcter~netl-throag'a-a-Boar~d-findi.-g. - - - - -- --- <br />4. I understand that statements in the application are being made 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 />Thu form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.RS., ojthe Colorado Land <br />Reclamation Ad for the Extraction ojConsdudion Materials Any aCeratian or modification ojthis jorm shag result in voiding any <br />permit issued on the altered or modifiedjorm and subject the operator to cease and desist orders and crvil penahies jor operaA'vrgwithoat <br />a permit pursuant to section 34-32-123, GRS. <br />Signed and dated this 3 ~`~ day of . ~~7'S <br />G-rang ~ruv <br />Applicant/Operator or Company Name <br />Signed: p~ <br />C ~~~ <br />Title: `U Lv V1 >!° Y' Ct- n ~ L ,o e r a ~e r <br />If Corporation Attest (Seal) <br />Signed: <br />State of 1 <br />ss. <br />County of CZR D moo. ) <br />The foregoing instrument was acknowledged before me this ~. day of <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />by <br />_ . _ C~_ ~-~-eP.-~-, <br />' LEE ANI~ ~~AUGHTtr-t Not Public <br />NCTARY PUBLIC 5 arY <br />STATE OF COLORADO , <br />,.., ~~,,,,., s:_ ~.,,, _~ My Commission expires: S -) S -p-~ <br />SIGNATURES MUST BE IN BLUE INK <br />M\minVharelnfams\Co~truc[ion tl2.doc (0728/2004) <br />