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~~-OI ~ <br />~2etix~l Cpl ~ ca~i o~ ~ <br />-S- <br />Certif`~cation: <br />r ~`` -; t~ <br />~- <br />f; <br />. - - -'i <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 />] . To the best of m;y knowledge, all significant, valuable and permanent man-made structures} in existence at the time <br />this application is f led, 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 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicant/operator, I donot have any extraetion/exptoration 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-I20, C.R.S.) as determined through a Boazd 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 i8-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 3d-32.5-112,C.RS., of the Colorado Land <br />Reclam anon Act for the Extraction of Construction Materials. Any alteration or modifccatian of this farm shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penaitles for operating <br />w&hout a permit pursuant to section 34-32.S-123, C.RS. <br />Signed and dated this _,,/ t~ day of ^ , 2 ~~.Z._.- <br />'~ ~~~ ~~; I~JC- ©'Lct STO,vi~ ~~ QI /~~14~r ~ j/`~~ • If Corporation Attest {Seal} <br />ApplicantlOperator or Company Name <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument: was acknowledged before me this ~ b day of_ YY~ , <br />~~> by 1 ~^ ~~_ ~ as ~'fgSt~U..~l}- of ~.' 0~ L - <br />p~P......... Vie" \ Notary Public <br />IWK E. ' ~~ ` ~~ <br />.~ My Commission expires: 1 I - <br />SIGNATURES MUST BE I1~T BLUE INK <br />M:iminsharelvsfimi~s~psm~~~l~roved OSfI li?005) <br />State of _ ~~~,~..LlA.,~~j ~J <br />ss. <br />County of ~~_(_~~._.,___._____) <br />