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~, <br />p r-.. <br />- 8 - i 7 <br />l! ~~ ~~`^~^~3j <br />C%;, - // <br />Certification: :"~:::: ; ~ "~i, <br />-- ~~;~;~ <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 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 34-32.5-115(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/aperator, I do not have any extraction/exploration operations in the State of Colorado currently in <br />violation of the provi:~ions 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 ar modifeed 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 />.. ~y <br />Signed and dated this =,~ day of ~~ !7 <br />~ ~~i ~ ~ ~ i I2 ~ L C y ~--~ ~. ~ ~ ~' ~ -~ ~`1~L~ ~ '~~~~ >~~LV ~ If Corporation Attest (Seal) <br />Applicant/Ope, ator or Company Name <br />Signed: <br />Corporate Secretary or Equivalent <br />~~~ ~s~; ~,~~%~ ~- <br />Town/City/County Clerk <br />State of °-- J ~ ~ '~G ~ s, ) <br />ss. <br />County of ~ `~ ~ ~ ~'e--~---) <br />The foregoing instrument was acknowledged before me this ~ day of ~~ `~ <br />~~~ by `,~ 5+r` - as ~L'~i <br />~f 1 ~ 'i / <br />~.n®f7~ <br />O~PRY P(,~ Notary Public <br />?•• My Commission expires: <br />SHANE <br />' ASKIN ' <br />'•. ~ SIGNATURES MUST BE IN BLUE INK <br />•••~''`~snr~.'~~•• fAonroved OSli l/2005) <br />WN Commission Expires Od 3.2008 <br />