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-8- <br /> Certification: <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 applicant/operator,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 detennined <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 I 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,C.R.S.,of the Mined Land <br /> Reclamation Act Any alteration or modification of this form shall result in voiding any permit issued on the altered or modified <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.RS <br /> Signed and dated this I r-A — day of <br /> I <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 _:�`\�1,�O\ (_�' <br /> \ _Q )ss. <br /> County of ) , <br /> The foregoing instrument was acknowledged before me this J day of <br /> by - �� ` v '� as 14 \'C_1\'-',,\\\_)(-- \� of hc�L� ��r�. <br /> i <br /> Notary Public <br /> My Commission expires: 0 L_aJ <br /> SIGNATURES MUST BE IN BLUE INK <br /> OFFICIAL SEAL <br /> CATHERINE _"NE <br /> NOTARv a.,B,.0-S-;-: .F ILLINOIS <br /> MY COMMISSION EX?>RES 06,'27'15 <br />