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-8- <br />Certif cation: <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 ofthe 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 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 understandthat 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 fora: has been approved by the Mined Land Reclamation Boardpursuant 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.R.S. <br />Signed and dated this day of aj- '�4t'1 r"C tip d <br />JRS Mining LLC <br />If Corporation Attest (Seal) <br />Applicant/OperaZompainy ame <br />3 <br />Signed: Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />Title: <br />State of C l_J6 r-�? Wo <br />' ) ss. <br />County of � C 1 t L <br />The foregoing instLument was acknowledged before me this day of kckrc y\ t <br />by cr"� i< ' i as V\Cc. of V t n, t �n c, . 114— <br />NOTARY PUBLIC <br />STATE OF ARIZONA T ' <br />Pinai County <br />ROSIO CORNWELL Notary Public <br />My Commission Expires January 29, 2019 ' <br />My Commission expires:, �a t1• <br />SIGNATURES MUST BE IN BLUE INK <br />