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r <br />-~- <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 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 aze prohibited bylaw (Section <br />34-32.5-115(4)(f), C.RS.; <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 (Section <br />34-32.5-120, C.RS.) as determined through a Boazd fmding. <br />4. I 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 day of <br />ApplicandOperator or Company Name <br />Signed: _ <br />Title: _ <br />State of <br />County of <br />ss <br />The foregoing instrument was~cknowledged before me this <br />by <br />as <br />If Corporation Attest (Seal) <br />Signed: <br />Town/City/County Clerk <br />day of , <br />of <br />Notary Public <br />My Commission expires: <br />Corporate Secretary or Equivalent <br />SIGNATURES MUST BE IN BLUE INK <br />M:U'LQ~'~BDC~MINFORMS~28I3C012APP ]0/17/01 <br />