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<br />-~- <br />Certification: <br />As an authorized representative of the applicant, 1 hereby certify that the operation described has <br />requirements of the following terms and conditions: <br />l . To the best of my knowledge, all significant, valuable and permanent man-made structu <br />this application is filed, and located within 200 feet of the proposed affec[ed area have been <br />(Section 34-32.5-I IS(4)(e), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by <br />34-32.E-1 I5(4)(f), C.R.S.; <br />3. As the applicantloperator, i donor have any extractioniexploration operations in the <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Cc <br />34-32.5-] 20, C.R.S.) as determined through a Board finding. <br />4. i understand that statements in the application are being made under penalty of perjury <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Signed and dated this ~_ day of ~ u nJ r' (9~ 9 <br />So. c.'A'~ e.n. <br />Applicant/Operator or Company Name <br />Signed: , ~ aI1 ~ . •~~ <br />Title: ~ 7C€- t" 2k-SId rn» <br />State of \ iO~I~R'(\c~t~ ) <br />ss <br />County of \~t~'~`l`vf~ 5Q ) <br />If Corporation <br />Signed: <br />t <br />The foregoing instrument was acknowledged before me~ilt~'s} a~ T day of. <br />Notary <br />My Commission <br />SIGNATURES MUST BE IN BLUE INK <br />the minimum <br />in existence at the time <br />~ified in this application <br />(Section <br />oFColorado currently in <br />:tion Materials (Section <br />that false statements <br />(Seal) <br />or <br />Clerk <br />~. <br />~-S-O~ <br />M.V.4NSFUR(:~YSFOILSISUl:JC012.APP OLIO/-9 <br />