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-~- <br />Certification: <br />As an authorized representative of the applicant, I hereby certifi~ 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 stmctwe(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.RS.). <br />2. No mining operation a-ill be located on Sands where such operations arc prohibited by law (Section <br />34-~2.>-lI5(4)(f), CRS.; <br />3. As the applicanUoperator, I do not have any exrtractionlexploration 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.RSJ 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 <br />made herein aze punishable as a Class I misdemeanor pursuant to Section 18-5-503, C.R.5. <br />""~~ <br />Signed and dated this ~_ day of M a-~ 2 r~ o z , <br />Moffat County Road Department <br />Applicant/C+perator or Company Name <br />Signed: ~. ~L,~, ~'~e< <br />Billy Mack <br />Title: Road Supervisor <br />State of Colorado <br />Coun of Nloffat jss <br />ty <br />If Corporation Attest (Seal) <br />"~ p,T,,~ pU~~a <br />~`; ~' . L. <br />~~~1~ <br />The foregoing instrument was acknowledged before me this ~ <br />by Billy E. Mack ~ Road Supervisor <br />of <br />or Equivalent <br />mty Clerk <br />Z <br />Notary Public <br />`~ ` `- <br />MVI~PBDC~t.~aNFORMS@823C012APP 04tl 9/2W2 <br />My Commission expires: 9'10 - zr-~-, ~ <br />SIGNATURES MUST BE IN BLUE INK <br />... •' C) <br />C,? R P~? <br />