Laserfiche WebLink
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(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.RS.; <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.SS, 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, CRS <br />Signed and dated this f 9 day of To i, u a v Y , vZ) / / . <br />Applicant/Operator or Company Name <br />Signed: <br />Title: Li. fi <br />State of C� t�k0 Cad. 0 ) <br />� (� ) ss. <br />County of l"ik PaSD ) <br />The foregoing instrument was acknowledged before me this <br />I , by Scot 17a■k <br />- 8 - <br />o -11 <br />as ��� of ��l.I1M[(jf G ' flJi f'lt�J'l <br />SIGNATURES MUST BE IN BLUE INK <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />blic <br />mmission expires: (7,30/1 - <br />