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-~- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and wnditions: <br />1. To the best of my lmowledge, all significant, valuable and permanent man-made structure(s) in existence at the time <br />this 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.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law (Section <br />34-32.5-115(4)(£), C.R.S.; <br />3. As the applicandoperator, I do not have any extractionlexploration 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.R.S.) as determined through a Boazd fmding. <br />4. l 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 />Signed and dated this ~ I ti day of ~~ l2 C H Z 00 3 <br />Costilla Countv Road & Bridge <br />Applicant/Operator or Company Name <br />Signed: ~~ (G~LGw ~~~ <br />Title: L~c9 w!~ ~'/~i- ~Gt p ~~ c~~ <br />State of Colorado <br />County of Costilla <br />ss <br />If Corporation Attest (Seal) <br />Signed: ~J (/L Q~ P.n ~ /L/l /7,~_ <br />Corporate Secretary or Equivalent <br />Town/CitylCou_nty Clerk <br />The foregoing instrumen't/ was ~a%knowledged be ore me this 7 t~. d y of Q~ , <br />by ~~h f t.tl V a 1 U f 7 as ~ C~ (of / ~~ i <br />:~~ ~ /` <br />No Public <br />My Commission expires: l>7 ~~ ~ (L_ <br />SIGNATURES MUST BE IN BLUE INK <br />M:NIPI~BDCNIINFORMS~2823C012.APP 10/17/01 <br />