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- -------- -- 8 . . <br />Certification: <br />As an authorized representative of the applicant, I hereby certifythat 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 tile 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 approvedby 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 resin 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 <br /> <br />Applicant/Operator or Company Name <br />Signed: 64C n <br />Title: <br />State of --- - -- - ----- -- ------) <br />)Ss. <br />County of ) <br />The foregoing instrument was acknowledged <br />by M??ttjjL?__a7 <br />Ott <br />. FRN <br />6;..••• <br />IfCorporati6il Attest (Seal) <br />Cpl poRA'«?. ? <br />Signed <br />Corporate Secretary or Equivalent <br />clay of <br /> <br />Notary Public <br />Town/City/County Clerk <br />1 ly Commission expires: ?? / r ^ _---_-._--. <br />S:IGNA'I'1i: ,RF,S MUST BE IN I3I..UE INK