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_g- <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) inexistence 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 applicant/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 are punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Boardpursuant to section 34 32.5-112, C.R.S, of the Colorado Land <br />Reclamation Act for the P,xtracdon of Construction Materials. Any alteration or modification of this form shall result in voiding any <br />permit issued on the altered or mod fled 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.R.S. <br />Signed and dated this S e e n n d day of Mil 2n ng <br />Lincoln County <br />Applicant/Operator or Company Name <br />Signed: <br />Title:Land Use Administrator <br />State of <br />) ss. <br />County of <br />The t<rregoing instrument was acknowledged before me this <br />If Corporation Attest (Seal) <br />Signed- <br />Corporate Secretary or Equivalent <br />Town/city/COtent 'CI <br />day of -- - - - --- ---- ?_ --• ` ', <br />__._> by - Kenneth Mom son as?_ IZS?_ Adm,___ of kincoln Count <br />uM M CKVARM <br />Notoiy Rf1Nk <br />Skft of coloreft <br />- CL a Al. A <br />Notary Public <br />My Commission expires: A <br />TUBES MUST BE IN BLUE INK