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-8- <br />Certification: <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements ofthe <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 />applicantloperator 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)(#), <br />C.RS. 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 ofthe provisions ofthe 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- 32412,CRS., 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 day of <br />JRS Mining LLC <br />If Corporation Attest (Seal) <br />Applicant/Operator o mpany acne <br />Signed: Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />Title: G I a <br />State of F—i dC f ) <br />) ss. <br />County of C 1 <br />The foregoing instrument was acknowledged before me this day of kU'CC_� , <br />