2009-11-30_REVISION - M2000156 ‎(7)‎

• Permit No: M2000156
• IBM Index Class Name: REVISION
• Doc Date: 11/30/2009
• Doc Name: Submittal
• From: Coulson Excavating Co., Inc.
• To: DRMS
• Type & Sequence: AM1
• Media Type: D
• Archive: No

ICE
Certification
As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum
requirements of the following terms and conditions:
1. To the best of my knowledge, all significant, valuable and permanent man- made structure(s).in existence.at the time
this application is filed, and located within 200 feet of the proposed affected area have been identified in this application
(Section 34- 32.5- 115(4)(e), C.R.S.).
2. No mining operation will be located on lands where such operations are prohibited by law
(Section 34- 32.5- 115(4)(f), C.R.S.;
3. As the applicant/operator, I do not have any extraction/exploration operations in the State of Colorado currently in
violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials
(Section 34- 32.5 -120, C.R.S.) as determined through a Board fmding.
4. 1 understand that-statements in the application are being made under penalty of perjury and that false statements
made herein are punishable as a Class 1 misdemeanor pursuant to Section 18 -8 -503, C.R.S.
This form has been approved by the Mined Land Reclamation Board pursuant to section 34- 32.5- 112,C.RS., of the Colorado Land
Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding any
permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating
without a permit pursuant to section 34- 32:5 -123 C.RS.
Signed and dated this o kY -1`1h day of
) 'oc' If Corporation Attest (Seal)
Applicant/Operator or Compdny Name 'R
Signed: C�
�u�-N� Ch��.sc�►�1
Title:
Signed: �s
Corporate Secretary or Equival nt
Town /City/County Clerk
State of c) "A/ )
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County of )
The foregoing instrument was acknowledged before
aP 7A), by K� �► N� C`a� �L►� as
Sean Cox, Notary Public Notary Public
State of Colorado
My Commission Expires 4/27/2011 My Commission expires: ] as t
SIGNATURES MUST BE IN BLUE INK
You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a