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- -- -------- ----------------..__. ... <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 fled, 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 />711sis 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 Extraction of Construction Materials. Any alteration or modification of this form shall restdt in voiding any <br />pernsit issued on the altered or modifled 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, CRS. <br />Signed and dated this day of <br />f4/&r/A.) AZCA,z&,q A <br />Applicant/Operator or Company Name <br />r ; "( <br />Signed: t '-1.1 rm? a <br />Title: <br />State of <br />County of <br />) ss. <br />The foregoing instrument was acknowledged <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />A o- day of <br />My Commission expires: 6 - / _l U <br />nC <br />SIGNATURES (MUST BE IN BLUE INK