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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 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 file;d, 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 aze prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicantloperator, 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 34-32.5-12(1, 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 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~t~d this ~~ ~, day of /~ ~~ ~ ~- , ="'_',~~~• <br />~~ ~~ J; <br />or Company Name <br />p~ If Corporation Attest (Seal) <br />Signed: <br />.~ - <br />State of / F q <br />ss. <br />County of L ~ / ~' ~'- / ) <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this ~~ day of ~.F'~ ' I , <br />`21~v~~by Tom SfT ~yGO~ as ~r'~s;~~. fi of J~~a.~ who[c s~ ~e <br />~'p1 <br />~Q~a••-- -''•~~~ ~ Notary Public <br />a •' , <br />16 /o <br />• ; SANE ; • My Gmmissian exrires: 3 <br />asKra <br />••,,,..••'• SIGNATURES MUST BE IN BLUE INK <br />ved 05/11/2005) <br />MV I:nmr.~iee.n~ Cvn~~ee f1M 3 'X1Iq <br />