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-8- <br />Certifieation• <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the <br />following terms and conditions: <br />1. This mining operation will not adversely affect the stability of any significant, valuable and permanent man-made <br />structure(s) located within two hundred (200) feet of the affected lands. (However, where there is an agreement between the <br />applicant/operator and the persons having an interest in the structure that damage to the structure is to be compensated for by <br />the applicant/operator (Section 34- 32- 115(4)(d), C.R.S. 1984, as amended), then mining may occur within 200 feet. Proof of <br />an agreement must be submitted to the Office prior to the decision date.) <br />2. No mining operation will be located on lands where such operations are prohibited by law (Section 34- 32- 115(4)(f), <br />C.R.S. 1984, as amended); <br />3. As the applicantloperator, I do not have any mining/prospecting operations in this state of Colorado currently in <br />violation of the provisions of the Mined Land Reclamation Act (Section 34 -32 -120, C.R.S. 1984, as amended) as determined <br />through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements made <br />herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8 -503, C.R.S 1984, as amended. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34- 32- 112,GR.S., of the Mined Land <br />Reclamation Act Any alteration or modification of thisform shall result in voiding any permit issued on the altered or nodified <br />form and subject the operator to cease and desist orders and civil penalties for operating without a permit pursuant to <br />section 34-32 -123, C.R& <br />t r' <br />Signed and dated this d� _ day of <br />Gold Basin, LLC <br />If Corporation Attest (Seal) <br />Applicant/Operator or Company Name <br />Signed: Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />Title: Member <br />State of`\ \� \O\ ) <br />ss. <br />County of \ _ Q�, ) <br />The foregoing instrument was acknowledged before me this `' day of <br />by ��5 ^� . as of_���L� <br />/ —) <br />Notary Public <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />OFFICIAL SEAL <br />CATI HERINE _vNE <br />NO?ARY LLINOIS <br />M _OMM SSJON EXPIRES 3&'27 15 <br />