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-g. <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the ntutimum rex)uiremertts 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 area have been identified N this application <br />{Section 34-32.5-1 IS(4)(e), C.RS.). <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.RS.; <br />3. As the applicandoperator, 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 finding. <br />4. [understand that statements in the application are being made under penalty of pcryury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18.8-503, C.R.S. <br />This form has been approved by the Mined Land RedamaCan Board pursuant to section 3d-32.5-f 12,CRS, ojrhe Colorado 4and <br />Reclamation Ad jot the Ezmracfion ojConatructlan Materials. Any aheration or modification ojthis jo~m skull resu@ in voiding any <br />permit vsued on the ahered or modifredjorm andsubjed the operator to cease and desist orders and civil penahYesjor operatiagrv®Iroid <br />a permit pursuant W section 34-35.5-123, C.RS <br />Signed and dated this ~ day of ~'~ ~ ~4a ~ <br />~c t V tG/W~ ~~.- If Corporation Attest (Seal) <br />ApplicantlOperator or Company Name <br />Signed: ~ *g"~" Signed: / <br />~~ ~ A ` , f~ ~ Corporate Secretary o Equivalent <br />Title: `11_~,,~ll/II~„' ~- Town/City/County Clerk <br />Statcof CYC'O/`C~l d ) <br />sS. <br />county of ~~ , ~r,J 1 <br />The foregoing instrument was acknowledged before me [his ~ O u ~ day of / t' U ~. , ~U~S , <br />by as of <br />SHARON R. CLARK Notary Public <br />~ ~ Notary Public, Bartow County, Georgia <br />My Comrr,ission Expires July 20, 2008 ~UU ~ <br />:~ My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />M:~nunbhuerv,(omu~Co,uwclion ~ I z Joe (Approved os/I In00s) <br />