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-~- <br />Certification: <br />As an authorized rept~eseatative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />I. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) inexistence at the time <br />this application is fled, 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 bylaw (Section <br />34-32.5-115(4)(f), C.RS.; <br />3. As the applicandoperator, I do not have a~ extracuion/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 (Section <br />34-32.5-120, C.RS.) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. <br />Signed and dated this ~~_ day of FGA , ~. <br />~,~,t ~ad12u~ ~a 0~ (ram ~c <br />Applicant/Operatar or Company Name <br />Signed: <br />Title: ~~fi~-t'~3~3~~~J <br />If Corporation Attest,(Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />TowdCity/Cormty Clerl: <br />State of I~~OV~aG$b 1 <br />ss. <br />County of ~ati~ ~~`~ <br />The foregoing instrument was aclmowledged before me this ~ ~ day of ~~ rte. by <br />~~f,i3e- ~(~170t-1- as QrQSi d.-Q.t~ of <SarhDrr\ ,~nr~ tl.(S1G,~~~,1, <br />.~ <br />Notary Public <br />~~ ~ <br />~~' ,~Cig L\C; p0~ My Commission expires: ~ r <br />SIGNATURES MUST BE IN BLUE INK <br />