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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 nequiremeots of <br />the following terms and conditions: `- <br />1. To the best of my knowledge, all significant, valuable and permanent man-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 will 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 arty extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Laad Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.RS J as determined through a Board finding. <br />4. I understand that statements in the application are being made under penally 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 />This form has been approred by the Mined Land Redmnoiion Board pursuant to seMion 34-32.5-112,GRS., ojthe Colorado Land <br />Reclamation Act for the Extraction ojConstruction Materials. Any aUeration or modifuation ojthis form shag result in voiding any <br />permit issued on the altered or modifredjorm and subject the operator to cease and desist orders and civil penahies jor operaturg withord <br />a permit pursuant to section 34-32-I23, C.RS. <br />Signed and dated this ~ day of . ~7T <br />G.rc~nd (,'ra~P( <br />Applicant/pperator or Company Name <br />Sig <br />Titl <br />State of ~K~ol~ts-~'~ 1 <br />ss. <br />County of ~c~-R_.Q ~ ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />/" Town/City/County Clerk <br />The foregoing instnunent was aclmowledge~d beIfore me this `~ day of _ ~7 5 by <br />i-~~ 6y^.iiu..:.A~/~ai1 Y ~t~ ~ V V~~~ /Mf~~'flr~M <br />NOTARY PUBLIC Notary Public <br />~y STATL OF COLORADO <br />- My Commission expires: ~ ~I SU'-] <br />SIGNATURES MUST BE 1N BLUE INK <br />nr ~~,ts~~„st~~co~e.~i~ i uaa <arizsnooa) <br />