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:~ <br />-~- <br />Certiftertinn: <br />As an authorized representative ofthe applicant, I hereby certify [hat [he operation described has met [he minimum requirements ofthe <br />following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 34-32.5-1 l0(1)(a)(Vlll). <br />~. To i"c best of;ttp kno\,-icdgc. ah significant, valuable and permanent man-made stmcture(s) in existence at the time this <br />sppGcst;on is Glyd, and I„~at;=a u;tkdr, 200 feet of [he proposed affected area have been identified in this application <br />(Sei.tion s4-32S-i i ~14)(e), C.R.S.). (NOTE: For 110 operations, the affected azea includes all lands delineated by [he permit <br />['uun;=2R~ ~i <br />_ . do miri;.g operntion ;will be located on lands where such operations are prohibited by law (Section 34-32.5-115(4)(t), <br />-L~~ <br />4. As the applicvttJOperatoz, I do nct have aar minine; explom[ion operations in the State ofColorado currently in violation of <br />the p?r>visions of the Colorado Land Reclamation Act for the Extraction of Constmction Materials (Section 34-32.5-120, C.R.S.). <br />I tuidcrsL_id :hat ;tatemcnts in the application are being made under penalty of perjury and that false statements made herein <br />a,['eilni=hahc a,aii 3-; i ~uisdemeanor pursuantto Section l8.8-503, C.R.S. 1984. <br />Th:s jorm Ires been appra.•ed b;~ the:tfined Land.~eelamatinn Board pursuant to section 34-32.5-110,C.12S., ojthe Colorado Land <br />Redarnatiar.,4ctf„r the Extraction r,J'ibrsxiructinn hfateriaLc Any alteration or modifecation ojtbisjorm shall resuU in voiding any <br />pe+•rnir issued a.. zhr ukerr-:t or nmrUJied jorm and subject the operator to cease and desist orders and civil Pena/ties jot operafrng <br />t;•irhouY .; per.~ilt purs;,.n.,=a€ rc- seen n 3442.5-123, GR.S <br />;i~aeu sod dstrd Lbis a~ day Of ~CilJ a'U- 'V O <br />r <br />ApplicantlOperator <br />Stkr!cd <br />9tatc of-_~.aLO Q.ap ~ 1 <br />ss. <br />Cet:ntyof ~9Gr- _) <br />If Corporation ,Attest (Seal) <br />Slgn <br />COrpC"8tC . CreLaly Or EgnlValenl <br />Town/City/County Clerk <br />3. `~ h~ V <br />Titc fcrcgoiug insu~umcnr t:~as acknotv._d^.d .,_fnrc me this ~.~ day of FEBek-0R-' ~, o2001e <br />_, ! ~' S-i~i~,Y/,tbtlL£ SjreE< as fYJ wJt.L of <br />(t p~nD Sza a72 , LC.e. ,,~ // <br />spy_~~~ L-Qjf~ f~, Notary Public <br />'` ~ ~C. <br />~tM1~z My Commission expires: 3 //O dOOz <br />BLUE INK <br />M:\min\share\vsforms\Construction110 (Approved OS/11/t~69jf"•• •~ <br />