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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 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 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 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 ST day of 1 D?t'1lkAl'U , <br />CO,YYN 11 1 P_tk i +S On S =n C <br />Applicant/Operator or Company Name <br />If Corporation Attest (Seal) <br />Signed (®1?? <br />Title: / ,/ <br />State of (1O ` O f A C1 O ) <br />) ss. <br />County of ' <br />?T(h?e foregoing instrument was acknowledged before me th r\ It <br />. _W1 <br />1LL, by 'Fr&n K C.AIM i N _*'l as <br />Town/City/County Clerk <br />ST day of ?an LkCXN <br />, <br />*Wttl of Co1MIIleft I q- SONS TnC <br />zy? Y_105otary?ublic <br />ORADO mmission expires: <br />_09 <br />Signe <br />Corporate Sa=T <br />t <br />or Equivalent <br />SIGNATURES :MUST BE IN BLUE INK