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_g_ <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements <br />of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent rnan-made structures} in existence at the time <br />this application is filed, and located within 200 feet of the proposed affected area 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-i 15(4)(f), C.R.S.; <br />3. As the applic,antloperator, I donot have any extraction/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.R.S.) 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 are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />.This form has been approved by the Alined Land Reclamation Board pursuant to section 34-32.5-112,C R.S., of tl:e Colorado Land <br />Reclamation Act for the Extraction of Construction 1aterials. Auy alteration or modification of this form shall result in voiding any <br />permit issued an the altered or modified farm and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit prrrsuanr' to section 34-32.5-123, C R.S. <br />Signed and dated this _?2 '~y day of r _ .2 O~ `' ~~~~`' ~}~~~ ~ ~~ <br />~/ /~,rQD~' T~~ ~ ~%//i,C~,1 nG If Corporation Attest (Seat•~ .. ~ c~ ,,,; J ~ ; -_ <br />ApplicantlOperator or (.,o zany ame ; ;,~ T ~~ ~~ ~ ,~^>~ ^ _ <br />~.,, ~ r. ,~ T. ~ ~: <br />(% ~ r ~ .-- Syr' <br />Signed: Signed: ~ ~'. y ~ r '* '^'• <br />C porate Secretary or Equivalent <br />Title: __'~ ~ ~~l~~Q S. Town/City/County Clerk <br />State of.--C~_Qt~~~!?____.-------____-} <br />,-~ . } ss. <br />County of --...1_...~~.I_~Oi?.f ................_._...__._......) <br />h <br />`I`he f2sregaing instrument: was aclrnowledged before me this .__-~~-._ __, ciav of .----1.~Q /~ <br />- _ - __ . <br />- -------- °f . -- - r .dr _ ..~.r.-- <br />-- --- ------- 1nG <br />DENISE GON7ALES <br />NOTARY PUBLIC - <br />STATE OF COIORl.DO No ary Publ' <br />y ommission xpires ' /l 0 <br />. . ~ <br />M:y Commrsston expires: _,_-,2~ ,4/ , 2!~/! <br />S[GNATEi:Etl~;S ;MUST B:E~ Iiti I3r.,t;°I~, I:~1K <br />