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-8- <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 andl conditions: <br />1. To the best of m}~ knowledge, all significant, valuable and permanent man-made structure(s) in existence at the time <br />this application is filed, and located within 200 feet of the proposed affected azea have been identified in this application <br />(Section 34-32.5-11'i(4)(e), C.R.S.). <br />2. No mining ~~peration will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-11'i(4)(f), C.R.S.; <br />3. As the applicar~t/operator, I do not 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 aze punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-112,C.RS., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form 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 penalties for operating <br />without a permit pursuant to section 34-32.5-123, C.RS. <br />Signed and d this ~~ ~Y of ~~ ~ ~-- ~ ~ <br />~ ~7- , I ~ ~rR~~ py,~ If Corporation Attest (Seal) <br />or C~~mpany Name <br />Signed: <br />Corporate Secretary or Equivalent <br />Title <br />T <br />Town/City/County Clerk <br />State of / o r °~ <br />ss. <br />County of ~ 4 r ~~ ~-e l ) <br />The foregoing instrument was acknowledged before me this ~_ day of ~~, <br />r` <br />'Zp~ ~ ~ by T ~- ~n L~ f ~ ~ 5 9 0 ~ as ~/'-~ s ~ ~ ~ A of <br />,~r <br />~Y'/1 . Notary Public <br />' ~~E * My Commission expires: l6 3 / ° <br />" ASN-tN <br />:, ,; <br />••'••..••!•„~!.••'• SIGNATURES MUST BE IN BLUE INK <br />,ns~Cons rJ• ved 05/11/2005) <br />(~nTTil Cinn CYI'~~'~Pf. nN ~ ^^^ <br />