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-~- <br />Certilication• <br />As an authorized representative ofthe applicant, I hereby certifythat the operation described has met the minimum requirements <br />of the following terms and conditions: <br />1. To the best of my Imowledge, all significant, valuable and pemtanent ntan-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 />(Sectioa 3432.5-I 15(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />{Section 34-32.5-115{4)(f), C.RS.; <br />3. As the applicant/operator, I do not have anyextraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extractiou 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 pery'ury and that false statements <br />made herein are punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.RS. <br />Thu jorm has been approved by dre Mbred Land RechrnraNan Board pursuant m section 34-31.5-1I2,GRS., ojlhe Colorado Land <br />Reclamation for the Extraction ojCoastruc6on Materials. Any alteration or modijlcation ajthis jorm shag resuU in voiding any <br />perms issued on the aUered or mod~d jorm and subject the operator to cease sad desist orders and civr7 penakies jor operating <br />witkout a permit pursuant to section 3441-113, CR.S <br />-nom <br />Signed and dated this ~ day of ~ '- <br />2~0 <br />l-~~.Gr~~k i~ 1NOtts-/~tl~s-WCr2/ <br />ApplicanUOperator or Company Name <br />Si ~ .t-~ <br />Title: ~ c fL 1~1'+-~ S~ O.GN j <br />r~ • ifCorporation Attest (Seat) <br />-^-•- -- <br />`~''-r-°~y- <br />.n, • z <br />Signed: <br />Corporate <br /> <br />,,~ _ ;_ `. <br />State of ~~~~~ 1 <br />ss. <br />County of <br />The foregoing0instrum' ent wasZ~owledged before me this ~ day of~b <br />~. ~;~ <br />Notary Public ~ - ; <br />::.~'•.. <br />t:-._ <br />My Comnrission expires: <br />SIGNATURES MUST BE IN BLUE l1YK <br />rt:~~sm2~~~cmn uz.~ rosrzvmoa> <br />