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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 follo-wing 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 applicant/operator, l 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 LandReclamation Boardpursuant to section 34-32.5-112,C.R.S., 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 R.S. <br />Signed and dated this day of -?'Awy , :00" <br />Applicant/Operator or Company Name <br />Signed:/ -- <br />Title: <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of C Of b ?-cx d C? ) <br />) ss. <br />County of --? d--f, \C <br />The foregoing instrument was acknowledged before one this __ac i _ day of <br />a OQ ft , by _C 7B y ). as of --- <br />OTAR-r <br />-a- 0 <br />N9?PU Ur'o? Notary Public U <br />F OF COV / <br />My Comm. Expires?OR My Commission expires: <br />SIGNA'Tts:Rli S MUST BE IN RLfi ?r I.1 K