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8- <br />Certifica6oo: <br />As an authorized representative of the applicant, I hereby certify that the operation descnbedhas rrret the minimum requirements oC <br />the following terms and conditions: , <br />i <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 in this application <br />(Section 34-32.5-1 l5(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-] 15(4xf), C.R.S.; <br />i <br />3. As the applicanUoperatoy I do not have arty extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Rxlarnation Act for the Extraction of Constmction Materials <br />(Section 34-32.5-120, C.R.S.) as determined througfi a Board finding. <br />i <br />4. I understand that statements itr the application are being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor ptasuant to Section 18-8-503, C.R.S. <br />i <br />This form has been approved by tire Mined Land Reclamation Board pursuant to sedian 34-32.5-ll2,CRS, ojthe Colorado Land <br />Reclamation Ad for the Fstradion ojConstrudion Materia& Any ahaatian or modification ojtkis jwm shall result in voiding any <br />permitissuedon a4e aAreredw modiftedjorm andsubjedthe opadar to cease anddeslstorder andcrvrlpenaEaesjor operaairgrlm4ou[ <br />a permit pwsuan[ to secrion 34-32.5-]23, C.RS. ~ ~,,.•~"""""'•1,,, <br />~•: <br />signed and dated this day of ~' uL. y ZQ~Io ; o <br />~ ~ 1 <br />Applican emtor Camp ame ~ <br />i <br />Signed: - ~ <br />Title: V. ( AC,~C'e.~~h~~ ~ <br />n <br />State of 1 D`~r0.d~ <br />County of c~1t-~lCoa] ) <br />[f Corporation Attest <br />~~. <br />'~ ~S <br />tie <br />~ ~ $1 <br />J ~w <br />1- W ~i ` t <br />,+I •• + <br />~ ~ f; <br />~'P~ 9. <br />~, Cor~orate Secrotary or E <br />Town/Ciry/County <br />e~nc ~ .l <br />1~ ' <br />~ \ "•ry1HIW <br />The fo1regoing instrumen~t{,w~as acknowledged befoie me thi `I~'rl day of ~ ~~D , <br />by l U 11~ ~~ 1 FV \ as of ~, ~ ~IV1f XI `111 <br />~' <br />(~E~~:_-~ir~ <br />Notary Public ~I~ <br />I ` 1 °~"'I <br />My Commission expires: ~I l Q 1 <br />I <br />SIGNATURES MUST BE IN BLUE INK <br />de:u,~,ve~~„r~,~c~,,,,e~ nz.a~ tnrpoven osn v~aosr <br />I <br />