PERMFILE135166

• Permit No: M2002059
• IBM Index Class Name: Permit File
• Doc Date: 5/17/2002
• Doc Name: Permit Application
• From: Moffat County
• To: DMG
• Media Type: D
• Archive: No

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Certification:
As an authorized representative of the applicant, I hereby certify that the operation described has met the minirrn,m
requirements of the following terms and conditions;
1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence az the time
this application is filed, and located within 200 feet of the proposed affected area have been identified in this application
(Section 34-32.5-115(4)(e), C.RS.).
2. No wining operation wilt be Iocated on lands where such operations are grohibited bylaw (Section
~4-325-11~(4)(f), C.RS.;
3. As the applicanUoperazor, I donor have any extraction/exploration operations in the State of Colorado currently in
violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section
34-32.5-120, C.RS.) as determined through a Board fording.
4. I understand that statements in the application are being made under penalty of perjury and that false statements
made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS.
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Signed and dated this ~ day of M a-( 2 r~ o z ,
Moffat County Road Department
ApplicandOperator or Company Name
Signed: % )_JGL~.~-!rY`c+U•4
Billy Mack
Title:
Road Supervisor
State of Colorado ~
Coun of Moffat ;ss
ty
If Corporation Attest (Seal)
OFF A~p~J'G c
~,. ~~ ~~
~~L"S~
The foregoing instrument was acknowledged before me this ~
by Billy E. Mack ~ Road Supervisor
or Equivalent
mty Clerk
-2.- ,
of
Notary Public
My Commission expires:
SIGNATURES MUST BE IN BLUE INK
Cp~Rnfl
M1MIN~BDCQvaNFORM5~2823C012.APP 04/19/2002