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''1 <br />-8- <br />Certification: <br />As an authorized represent;itive 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 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 applicandoperator, 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 th;~t 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 ojthis 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 />`~~= 2 <br />Signed and dated this ~i day of ~ l~" `~ <br />Applicant/Operator or Company Name <br />~~'~~~ If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />/~ ~, S 1 ~J,~C~~ T <br />Town/City/County Clerk <br />State of ~- b 4 mac' <br />ss. <br />County of ~ 4 ~ ~ ~'^~ '~ ~ <br />The foregoing instrument was acknowledged before me this `~ day of ~ ~ y , <br />~U ~~, bY~ M Sf•~-' as ~r~~ ~~.~~- of S ~Glv E L,d~~ :~ ~. <br />I~® <br />O~~T.~!'~(~~~ Notary Public J <br />a '~ My Commission expires: <br />'~ r.'+~ SIGNATURES MUST BE IN BLUE INK <br />•~ti.~~~r <br />sire (Approved 05/11/2005) <br />W CerrMniMlen ExeNea Od S. ZI10o , <br />