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-8- <br />Certitica#ion: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements <br />of the folto~ving terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made structures} inexistence 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. 1Vo 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 applicantioperator, .I do not have any extractionrexpIoration 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 :Yfined Land Reclamation Board pursuant to section 34-32.5-112,C. R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction ~1~laterials. Any alteration or modification of this form shall resrdt in voiding any <br />permit issued on the altered or modified farm and subject the operator to cease and desist orders and civil penalties for operating <br />without a permitprtrsuant to section 34-32.5-723, C.R.S. <br />Signed and dated this ~ 71` day of ,~„ , ~~ <br />~, <br />aG 0.S ~ R~1tjCriC~ SSiO~n. <br />Ap ' antlOperator or Company Name <br />Signed: <br />Title: _ <br />If Corporation Attest (Seal} <br />Signed: <br />Corporate Secretary or Equivalent <br />Town,'City/County Clerk <br />State of-j_~-----_--~_-~_} <br />} ss. <br />~:ounty of <br />_....._. <br />`l`lic: t€Prego~r.g in ,~ untent was aclcno=.vledgt:d b~ cf:re mc: this .__.._~'~~ da~,• of .._. ~!~'~-~...____........_. _...__----.-..., ~~ <br />.~ <br />_._.-_...• by tz1~~~_~~i~r~s.~-4~~5idv~_5..._....- a` ------~~.~~~,----..-_._._......--_-........__..----- of.--- --~S-fxn~-_. ..-.'~.------- ..... ------__..._.....-.._.._ <br />1.1 --~ --- - ' - - <br />w, <br />Nbta Public d° "' ~'~~ ~ ~°. ~~.~°°9 <br />ere ~ "~!^ li a <br />o <br />u: .d <br />M:y Commission expires .,.;t-'I ,~~-_~._~ ~~~~;-ry <br />~'ti -- .~„~-~"~ ~ .e <br />SIG:~iA'TT~ltES StU~T E3E.Iti t3I.;E.`>~ I~1K "~'°_°a -? ~ ` ' ~' <br />° r~ 'y\ <br />Te` ~ ~;^. <br />