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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 conditions: <br />1. To the best of my knowledge, 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 area 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 aze prohibited by law <br />(Section 34-32.5-I15(4)(f), C.R.S.; <br />3. As the applicant/operator, I do not have any 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.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application aze being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-II2,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction ojConstruction Materials. Any alteration or modification ofthis form shall result in voiding any <br />permit issued on the altered ar modified jorm and subject the operator to cease and desist orders and civil penalties far operating <br />without a permit pursuant to section 34-32-123, C.R.S. <br />Signed and dated this \\'~`~ day of S Al~1yAQ `!< d OAS <br />If Corporation Attest (Seal) <br />ApplicanUOperator or Company Name <br />Signed: _Z~~~S~ J Signed: <br />Corporate Secretary or Equivalent <br />Title: ~ SCE Q RES~DE~T Town/City/County Clerk <br />State of ~~~/tVO1S ) <br />ss. <br />County of C/oo,~' ~ <br />The foregoing instrument wa~+s acknowledged before me this //~ day of ~~`~- e20Ou~ <br />_, by .~oSEi~N S SuM as VIeE ~z~'s/1~~-,>)T of r,'o~t/TIAJEI,j-TgL MATiE1t)A19C.'~ <br />~~1~VJ • / 1 u..vcl~ <br />OFFICUL SEAL Notary Public <br />ANNENiARIE 8 NUSEKABEL <br />NOTARr~PUBLIC.sTATEOFILLri016 $-aa -o $ <br />Mvt.04MSgIpN8~112tq My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />~,O 1 <br />M:\miv\yhaze\vsfomvs\Covstructiov 112.doc (07/28/2004) <br />