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-8- <br />t'erlilication: <br />As an authorized representative of the applicant, i hereby certify that the operation described has met the minimurn 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 raining 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. l 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 i misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This form has been approved by the Hined Land Reclamation Roard pursuant to section 34-31.5-112,CR.S., of the Colorado Land <br />Reclamation ; t ct for the Extraction of Construction ;Materials. Any ny 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 - _ ,,2op . <br />Moffat County Board of County Commissioner <br />ff Corporation Attest (Seal) <br />Applic anU'Oper for or Company Name <br />Nigne d,`-?_ s, b'ne - - <br />j? .3 Corporate Secretary or Equivalent <br />Title: &I Y^Yy AA-N r?VC? i Town,'City/Cou y Clerk <br />State of PLO <br />) ss. <br />County of <br />L,'- - - } <br />The foregoing instrument was acknowledged before me this day of <br />by as_ of <br />l-? <br />No ary Public <br />My Commission expires: <br />?SIGNA I I RFS MUST BY IN BF.I'F: INK