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-~- <br />Certification: <br />As an authorized representative of the apphcant' 1 herelrv certifi that the operation described has met the minimum requirements <br />of the followvtg terms and conditions: <br />1. To the best of my 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 area have been identified ¢t this application <br />(section 34-32.5-1 U(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-11~(4)(f), <br />C.RS.; <br />3. As the applicant/operator,l do not have any extraction exploration operations in the State of Colorado cturently N <br />violation oC 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 tJtrough a Boazd fmding. <br />4. 1 understand that statements in the application are being made under penalty of per}ury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS. .. <br />Signed and dated this ~ day of <br />'UlIdN <br />ApphcandOperator or Company Name <br />Signed: <br />/~ <br />~ ` If Corporation Attest (Seal) <br /> <br />Corporate Secretary or Equivalent <br />Title: - /)??¢ M/~~ty . <br />State of.~~1/ ~_.0 ) <br />,County of ~ ~Qs2~ l ss <br />Tovvn/City/Cotmty Clerk <br />The foregoing instrument was acknowledged before me this /`/'~` day of OL-c~L-7ln/i.~fL~Z- ZO o o , <br />bV .eO~~yLTC. STj9C~ r7,c~, a5 i1li~X/ih`>L-~~L Of- ,C~/ l,(XJYc.f/, GGC. <br />Notary Public <br />My Commission expires: ~ d U ~ <br />SIGNATURES MUST BE IN BLUE INK <br />M:~\thaeh~ro,rm~2i27COIlAPP (07/17ROW) <br />