Laserfiche WebLink
Applicant/Opera s • ompany Name <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements 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(4Xe), 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(4Xf), 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 />• <br />Signed and dated this 1 f day of 4 " 0 , 1 . , - <br />A , <br />d. <br />3 f � 1T. :'∎ !. <br />j �= <br />T PA/ E 1JJ *DOE D9-&. 1 i /4C, If Corporation Attest (Sear -z = - ; s <br />"N. .... 1 <br />4 n - w 1 <br />.... ' 1 • N m <br />• Signed: — �""%2� — +• �� Signed: '`" ---' <br />Corporate Secretary or Equivalent <br />Title. F Y / " a/ Town/City /County Clerk <br />State of C n l O re .c.i D <br />) ss. <br />County of 1 .,.1 tvvutAr ) <br />The foregoing instrument was acknowledged before me this tr.' day of <br />r l ()\ \, b y S k Yr “ JS o uD as Y f e.S \c3JA\ <br />J <br />0, ' <br />= P, .... PEW/ <br />I OTA/? N. <br />A \ '- : o <br />N�S8ion l Exp`le <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a <br />- 8 - <br />SIGNATURES MUST BE IN BLUE INK <br />u Public <br />of S- Ao 'ULlti CSIfL ! NC . <br />CG <br />My Commission expires: Q J2'1 fri d 1 Z <br />