2004-11-09_REVISION - M2000016 (14)

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-~- Certification: As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the following terms and conditions: I. To the best ofmy knowledge, all significant, valuable and permanent man-made structure(s) in existence atthetime this application is filed, and located within 200 feet ofthe proposed affected area have been identified in this application (Section 34-32.5-1 IS(4)(e), C.R.S.). 2. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-115(4)(f), C.R.S.; 3. As the applicant/operator, I do not have any extraction/exploration operations in the State of Colorado currently in violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section 34-32.5-]20, C.R.S.) as determined through a Board finding. 4. I understand that statements in the application are being made under penalty of perjury and that false statements made herein are punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.R.S. T/ris jorm Iras been approved by the Mined Land Rednmatlon Ronrd pursum~t to section 34-32.5-112,C. R.S., of flte Colorado Land Reclamation Act jor the Extraction ojConstruction Materials. Any alteration or modification ojthis form shall result in voiding nny permit issued nn [he a/tered ar modified jorm and subject the operntor to cense and desist orders and civil penalties jar operating without n permit pursuant to section 34-32-123, C.R.S. Signed and dated this l ~ day of ~ ~)~~ ~!' , ~~. Title: /~~G !nti ~4 (y ~p , i State of ) ' I I P~~1 s. County of ~p ~-'~ ) If Corporation Attest (Seal) Signed: 'r ~• L ...~.....,~~ /- Corpora Secretary or Egyhr~etytt~.~ ~:.~. us'; ~ V The foregoin instrument was acknowledged before me this day of ~nUPIMV1Lf i AVO~ ~~~~ ,"""" ~x~ by T~c1~ (';hih~i~.r as nf~c~~n~ IQn~ No oA-4J`, - ~~~~ 8 L t G•oc~ •''1l5~~~cmisnvicem~ uzao~ to~asnooat Notary Public My Commission expires J~- J~7' SIGNATURES MUST BE IN BLUE INK