Laserfiche WebLink
-8- <br />Cerh- ficat>ion: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements 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)(0, 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 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.R.S., of the Colorado Land <br />Reclamation Actfor the Extraction of Construction Materials Any alteration or modification of this form shall result in voiding any <br />permit issued on the altered or modlfed fore 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 day of aA Q , Zl?D <br />I <br />r A? r oe A <br />ide If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Signe <br />Title: <br />r / <br />State of aJo r4do ) <br />) ss. <br />County of MO! 4 a n <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me thi day ofLJ a VL (L , <br />24 5 by S Mr 4 Cr as of <br />1t1174.r11 r ^/F'li <br />Aet <br />EL? <br />' o ublic <br />- ? ? ,> = My Comrlission E#ea <br />?.. My Commission expires: 06123(2007 <br />SIG 1?K ? 13E IN BLUE INK <br />W nin\shuekvsfomts\Constntaion 112.doe (Approved 05/11/2005) <br />'fir z+Rt+? ; i !is