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-8- <br />Certiflestion: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements <br />of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and pcmianent man-made strncture(s) in existence at the time <br />this application is filed, and located within 200 feet ofthc proposed affected area have been identified in this application <br />(Section 34-32.5-115(4xe), C.R.S.}. <br />2. No mining operation will be located on lands where such operations are pmhibited by law <br />(Section 34-32.5-115(4~f), 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 />{Section 34-32.5-120, C.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application aze being made under penalty of perjury and that false statements <br />made herein aze punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the MJned Land Reclamation Board parsaant to section 34-31.5-111,C.RS, ojthe Colorado Land <br />Reclamadon AnjortheF,ztracdon ojConsnrrcNon Materials .iny altemti'on ar modiJ?<atlon afthtsfarm shall resah'at vofding any <br />permit issued on the altered or modified farm and subJect the operator to cease and desbY orders and civil penahles for operating <br />without a permit parsaant to section 34-31.5-123, CRS <br />Signed and dated this / ~ f~day of ~c~ ,Zoo ~ <br />~/Gkrt/l/ C7~~LC 1, ~" <br />ApplicanU for or Company Name <br />Signed: ~~~./.+.~/~ <br />Title: L ;,r ~~ /c~. <br />State of ~ ~ Olio-`~ ) <br />_ ) ss. <br />County of 1 <br />The fore oing instrument was acknowledged before me this 1 ~~3 <br />.r- q <br />~~'y` :~~ .,, <br />!~ A~i~ _ <br />/f , <br /><.0 -11i e <br />If Corporation Attest (Seal) <br />-- / <br />Signed /~ <br />_ Corporate Secretary or Equivale <br />Town/City/County Clerk <br />day of <br />~,~1~ of ~ L~~W C <br />rn ~ _ <br />Notary Public <br />My Commission expires: ~ 6 <br />`` ST BE IN BLUE INK <br />t, <br />M:~minkhareWS(~m~sK;m,tttw;iion 112.doc~l~AppfOved 051 <br />~r <br />..` <br />..~~ <br />