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- ~ - ~i s ~.~2 -~o b~ C~.7r rec,~ <br />erlification: ~~}°'r~ <br />~~~~ <br />s an authorized representative of the applicant, I hereby certify that the operation described has met the minimrmirequirements of <br />e following terms and conditions: <br />1. To the best of my lmowledge, 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 in this application <br />(Section 3432.5-115(4)(e), C.RS.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section34-32.5-115(4)(f),C.R.S.; - <br />3. As ttre applicanUoperator, I do not have any exttaclion/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.RS.) as determined tluough 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 />his jorm has been approved by the Mmed Land Reclamation $oard pursamd ro sedan 34-32.5-112,GRS, oj'the Colorado Land <br />'eclamafion Ad jor the Extradion ojConstruction Materials. Any aheratian or modificadon of ibis form shag resuC hr voiding any <br />rrmit issued on the aCered or modifiedform and sabjedthe operatorW cease and desist orders and czvilpenalties for operwA'vtgwi<lrou! <br />permitparsaant to sectionp3~4J-'3~1-I23, GRS. /,~ . <br />igned and dated this ~= day of fW/~'~t-~'-~-~~ 020 ~S~ <br />' •I a ~ ~ ~(ur d t%~td-1ti~t ffCorpcuation Attest (Seal) <br />ApplicanUOperator ~r Pant' Name ~ L G141/+-D <br />igned: /1 ~ ~ ~ ~,,' ` ~, /~ <br />'itle: l~ ~ rl'YI Q.I~C- I (~C~ ~T ~ <br />~yiryu/J ~ !~~~me,/r~ <br />tateof (~G~Y~r~~ } <br />.~ y ) ss. <br />'he foregoing instrument was aclmowledged <br />e as~ <br />~~~~ <br />•°` -•.,.; V orate Secretary or Equivalent <br />•. <br />~~~~ •;. Town/City/County Clerk <br />PLO <br />day of ~~. by <br />~~ of <br />Notary Public ~y ~ ~,, <br />My Commission expires: ~Cr[/(~'I [~ <br />SIGNA'IATIJST BE IN BLUE INK <br />c~~,eu~~~~c~,eonri2am (mnenooa~ <br />