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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 stmcture(s) in existence at the time <br />this application is filed, and located within 200 feet ofthe 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 are prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State ofColorado 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.j as determined through a Boazd finding. <br />4. I understand that statements in the application are 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.RS. <br />This form has been approved by the Mined Land Reclamation Board pursuard to section 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation Ad jor the Extradeon of Consbudion Materials. Any alteration or mod~crrtion of this form shall result in voiding any <br />permit issued on the altered or modified form and subjed the operator to cease and desist orders and civil penahies for operating <br />without a permit pursuant to seclian 34-32-123, C.RS. ~ ,~,c~ ~- <br />Signedand dated this _~~ day of Z , ~. <br />/1° /L!l ~/ • C~ ~ ~ If Corporation Attest (Seal) <br />ApplicantlOperator or Company Name <br />Signed <br />Title: ~~/ t~ ~/~ <br />b <br />State of L-P)/c'/df~O <br />County of c~~ade-cam ) ls. <br />The foreg~o~in~~in~sitrum/ent was acknowledged before me this <br />by _'.~`! f~..-~r-~-'F as <br />SIGNATURES MUST <br />M:\min\share\vsfomss\Construction 112 dnc (072812004) <br />Signed: <br />Corporate Secretary or Equivalent <br />day of <br />of <br />.- <br />~~ ~ ~. <br />~ '~ `' <br />~q ~~' <br />.`w- <br />Town/City/County Clerk <br />expires: ~ ~ ' ~ r O[`7 <br />