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., <br />-g- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirerttatts of <br />the following terms and conditions: <br />!. 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 afTected area have been identified in this application <br />(Section 34-32.S-I1S(4xe), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4xq, C.R.S.; <br />3. As the applicanUoperator, l do not have atry extractionlexploration operations in the Stato 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.RS.) as determined through a Board fording. <br />4. (understand that stakments in the application are being made under penalty of perjury and that false stakmettts made <br />herein are punishable as a Class (misdemeanor pursuant to Section 18-5-503, C.R.S. <br />Thu Jorm has been approved 6y the Mwed Land Reebmarion Board parsaad w recaion 34-32.5-/73,C.RS, ojthe Cobrado Land <br />Reclamation Ad ja, sloe EraaAson ajConstrrrrtion Mate~ia& Any accretion or madifunma ajdsirja~m sbaB ruahin voiding any <br />permcissaedon dre acertdo/ modijadjorm andrab/edtbe operaEartoeeasemrddtrirtorders andcivi[penacicrjoropaaoffag K+~IFarR <br />q pnmir pwsaant to acclion 34-32.5-/23, C.RS. <br />Signed and dated this .?~ day of y'= ~~rtQmC <br />6t>,25Cc~ ~ t121x a ~1 ,'rl v~ ~rnt A~a~q, ~w<C, IC Corporation Attest (Seaq <br />ApplicannUO-p~erator or Compatry(~amle <br />Sigra:d~~, G. to rr. ~ c,~. C ,c^t ltroa~ q Sigrred: <br />retary or Equivalent <br />Title: ~-~-~~. ~ ~ Town/City/County Clerk <br />State of ~Or~ ~!b O 6 } <br />ss. <br />County of 1,-t~~~ m~2 1 <br />The foregoing instrument was acknowledged before me this o2 ~ ~ day of ~'>"~Ytl ~ ~ • •' ; <br />by as of <br />~.-~ <br />Public sQ1.9Ti:••....•• <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />na~~w~~.+r~,,,,,•ca.,vm~a, ~ iz a~ In~rea osn tnaes> <br />