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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation describedhas met the minimumrequirements of <br />the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and pemianentman-made structure(s) in existence at the time this <br />application is filed, 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. 6e located on lands where such operations are prohibited by law <br />(Section 34-32.5-1 l5(4)(f), C.RS.; <br />3. As the applicant/operator, I do not have a~ 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 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 made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. <br />Tkis form has been approved by the Mbred Land Reclamation Board pursuant to section 34-32.S-ll$CR.S., ojthe Colorado Land <br />Reclamation Ad jor the Extraction of Construction MaterlaLc Any aheration or modi, flcah'on ojthis form shall result in voiding any <br />permit issued on the abered or morGfred form and subject the operator to cease and desistordus and civilpenaUiesjor operadngxs7hout <br />a permit pursuant to section 3¢31..123, C.RS <br />Signed and dated this ~ L, day of ~ a ~ ~l . Z ~~ . <br />~~ rn tan,~1 h2 ~ ~,rc hP ~_ ~c~C,. <br />AppficantfA erator or Compaq Name <br />Signed: ~., ~ ~ .~~ ,_ <br />Title: ~~ /?~Q.(.IJ/l~ <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of W`©~ <br />County of ~0.~ ~ ss <br />The foregoing instnmrent was acimowledged bce~fo~re me this 20 day of Sl~.1U ~ ~ Q~ <br />by 12x-c-~.1 (~O. rna~4~ as i C~'cnt'c~C~cM9. ~~~ of ~~ n.~ Ytc,Y1£ 1 L~i~it~l'' <br />`,`,`~~ungrirrr, ~ ~' \ <br />A s Notary public <br />.eev <br />!°UBLIG ? PO My Commission expires: ~~ ~ u- 2..~ lG <br />SIGNATURES MUST BE IN BLUE INK <br />