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<br />,~~; ~~ z <br />RECEIVED <br />'i/aL o~ yv~ -1x48-o~a~ <br />dc, C' ~ -( <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of <br />the following terms and conditions: <br />1. To the best ofmy 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 azea 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 ]ands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), C.RS.; <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 3432:5?120; C>R&:) as determined thiough a Board 5nding:--- - <br />4: I understand that statements in the application are being made under penalty 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 approved by the Mined Land Reclamation Board pursuant to section 34-32.S-I12,C.RS., ojthe Colorado Land <br />Reclamation Ad for the Extradio» o, f Construction Materials. Any alteration or modifuation ojthis form shaII result rn voiding any <br />permit issued on the a%tered or modifiedjorm and subjed the operator to cease and desist orders and civil penarYies jor operatbigwhhaut <br />a permitpursuanito sedion 34-32-123, C:RS. <br />Signed and dated this ~j~ day of . c7'~~7'S <br />G-rrzn~ ~'~~v <br />Applicant/Operator or Company Name <br />Sigued: <br />Title: CJ Lv Y1 ~ Y' Ct- It ~ L ,o C' /' Q ~a Y <br />State of ) <br />ss. <br />County of G~_.e ~la 1 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was aclmowledged before me this ~ day of~ ~ ~~ , by <br />P.`.a Jti~ ^.-I- F ~.tv~ r~-~. as c~'j---~s.~-e-o ~ , ~n~,ef _ ..,,.~. r~,. ~~ ,°'~ . <br />LEE ANN ~LAUGHTEF; ~ No Public <br />NOTARY PUBLIC ~ ~S' <br />STATE OF COLORADO ; <br />My Commission expires: <br />I~Ay Cornmissfcn ExpirasvS; IcJ:~.::i? <br />SIGNATURES MUST BE IN BLUE INK <br />bf~min~shaa~vsfo[ms~Co~tn¢tion ~il.dac (o7rzanaoa) <br />