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-7- <br />an authorized representative of the applicant, I hereby certify that the operation described has met thenvnimwnrequiretnents of <br />following terms and conditions: "' <br />1. To the best ofmy knowledge, atl significant, valuable and pertnanentman-made structure(s) inexistence at the time 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 wilt be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(fj, C.RS.; <br />3. As the applicant/operator, I do not have any extractionlexploration operations in the State of Colorado cmrendy in <br />violation of the provisions of the Colorado Land ]teclamarion Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.RS.) 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 made <br />herein are punishable as a Class i misdemeanor pursuant to Section 18-8-503, C.RS. <br />17ris form has been approved by the Mmed Land Reclamation Board pursuant to section 34-32.5-11$GRS, of the Colorado Land <br />Reclamation Ad jor the Ealradion ojConsbudion Alaterials. Any alteration or modificatiox ojthis jarm shall resnU in ~oido+g any <br />permitissued on the altered or modijiedjorm and subject the operator to cease and desist orders and civil penallias jor operaa'vrgwitliout <br />a permit pursuant to section 34-32-123, C.RS. _ <br />r .f <br />Signed and dated this ~~_ day of oC DO , <br />/V <br />State of L-0 0~('Q d C <br />M ) ss. <br />County of ! ' I o~~"' 1 <br />Theme f_oregoin instrument was aclmowledg before me <br />U L7Y~a 1~ ~ S'f.2e ~ ~ as C~- j <br />Q' -~...-.... ~':~ <br />;~~ ~ - - <br />= Q...• - <br />if Corporation Attest (Seal) <br />Signed: <br />:"- = ^ <br />r= _ ~^~=- <br />~,;.. , <br />.:., <br />__ 'J'l ~_ <br />c ~ ~' c. = <br />Corporate Secretary or Equivalent <br />Town/City/County Cierk <br /> <br />Notary Public ~ <br />My Commission expires: ~ ~ l ~ b <br />SIGNATURES MUST BE IN BLUE INK <br />~-' <br /><ornanooo) <br />Title: ~-4r~-~_/~S<~~ec~ <br />