Laserfiche WebLink
Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements <br />of the following terms and conditions: <br />4. 1 understand that statements in the application are being made under penalty of perjury and that false statements <br />made heroin are punishable as a Class 1 misdemeanor pursuant to Section 18-8 -503, C.R.S. <br />This form km been approved by the Mined Land Reclamation Board permeate to radian 34 32.5-112,CRS., eat Colorado Land <br />Reclamadon&etfar the Extraction ofConstruetion Materials. Any alteradonormodjflcation ofthisform shall remit in voidingary <br />permit issued on the altered or modified firm and subject the operator to cease and deist orders and civil penalNa for operating <br />without a permit pursuant to section 34 -32.5 -123, C&S <br />Signed and dated this J day of /VO ✓a -r _ <br />aialee4,MC Sit/ Gi�/ /0c, <br />tie40 c4,, r 4 eenactir, e J <br />Applicant/Operator or Company Name <br />Signed: <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(4xt), 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 Aot for the Extraction of Construction Materials <br />(Section 34 -32.5 -120, C.R.S.) as determined through a Board finding. <br />Title: //. <br />9 <br />State of C:dOrael <br />) sa. <br />County of e;) <br />The fore instrument was acknowledged before me this <br />-_. by Tier J S as L act es <br />-8 - <br />SIGNATURES MUST BE IN BLUE INK <br />2011 <br />If Corporation Attest (Seal) <br />• <br />Signed: <br />C• . to Seer to •Equivalent <br />Town/City/County Clerk <br />day of , <br />Lf1 6n94 f c.. <br />� ,�.tJct s <br />r-se4 "-2 `> 1 <br />Notary Public <br />My Commission expires: ,/. r; l 4 oZt1iJ� <br />of <br />Lt <br />Ake—got <br />