Laserfiche WebLink
_g. <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation describedhas mettheminimrmi requirements of <br />the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and pem~anent 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 in this application <br />(Section 34-32.5-115(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 applicaat/operator, I do not have arty extraction/exploration operations in t}ie State of Colorado carient]y 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 />This form has been approved by the Mined Land Reclamartion Board pursuant to section 34-3Z.S-112,GRS, ojthe Colorado Land <br />Reclamation Ad jor the F.axracfion ojConstruction Matesials. Any ahua&on or modiJicak'on ojthis form shag result in voiding any <br />permit issued on the abered or modifaedjorm and su6jed the operator to cease and desist orders and cavilpenalties jor opuatbegwithout <br />a permit pursuant to section 3~32.S-I13, GRS <br />Signed and dated this ,~~ day of / V 1) 1 C "~ ~t ~ ~. <br />_~_Idc.;~}~~ _Q_W Grey. .-LnC.._--. <br />r~li rl 11i.n ~+C~.1 l.~,M Dr~..v+ty a~' /'1P.S'a CdLt.1~`~ <br />Applicant/Operator or Compaq Name U <br />Signed: <br />Title: t~res,denk- <br />If Corporation Attest (Seal) <br />Signed•~ _ <br />Corporate S tary or Equivalent <br />State of ~ v\ uv4 ao <br />ss. <br />County of IY~e.Sg ) <br />Town/City/Cormty Clerk <br />ti <br />The foregoing instrument was acimowledged before me this 1 tv~' day of N o~evr,bt,d -Zoo 5 <br />by C.y-a;~ 1.avv_ her <br />of o, ~ra~4ar S~ (e nx.~`s~c. <br />1`nw'. V~,v:,-iecl Cwn~YUrS of rf4.oaerx+~ <br />Die ~~~ • - Q Notary Public <br />~~ ~a <br />,.;~~ My Commission expires: 3•t9•o9 <br />MUST BE IN BLUE INK <br />M:tmin~tMre\uxb~.\Camtructioa i72doe (Approved OS/1IR003) <br />