2012-01-13_REVISION - M1992058 ‎(5)‎

• Permit No: M1992058
• IBM Index Class Name: REVISION
• Doc Date: 1/13/2012
• Doc Name: Conversion Application
• From: Colorado Quarries, Inc.
• To: DRMS
• Type & Sequence: CN1
• Media Type: D
• Archive: No

-8-
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) inexistence 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 finding.
4. I understand that statements in the application are being made under penalty of perjury and that false statements made
herein are punishable as a Class I 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.R.S., of the Colorado Land
Reclamation Act jor the Extraction of Construction Materials. Any alteration or modification of this form shall resuh in voiding any
permit issued on the altered or modifred form and subject the operator to cease and desist orders and civil penaltes jor operating %ithmd
a permit pursuant to section 34 -32.S -123, C.R.S.
Signed and dated this I I day of J a ' # -
Colorado Quarries, Inc
Applicant/Operator or Company Name
Signed
u'
Title: 6 (.� -
State of )
) ss.
County of ✓e, w `� )
a &/a .
If Corporation Attest (Seal)
Signed:
Corporate Secretary or Equivalent
Town/City /County Clerk
The foregoing instrument was acknowledged before me this �� day of — J � � v
by _— � % / 2 el (C_ as P ✓C C i Al c c �, �'" of
NICOLE �KRAUTH
NOTARY PUBLIC
STATE OF COLORADO
MY COMMISSION EXPIRES 1002012
My
SIGNATURES MUST BE IN BLUE INK
,::;)b is
expires:
M "minlshere\vsfomm \Conwuction 112.doc (Approved 05 /11/2005)