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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 structure(s) <br /> located within two hundred(200)feet of the affected lands. (However,where there is an agreement between the applicant/operator <br /> and the persons having an interest in the structure that damage to the structure is to be compensated for by the applicant/operator <br /> (Section 834-32-115(4)(d),C.R.S. 1984,as amended),then mining may occur within 200 feet. Proof of an agreement must be <br /> 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),C.R.S. <br /> 1984,as amended); <br /> 3. As the applicant/operator,I do not have any mining/prospecting operations in this state of Colorado currently in violation of the <br /> provisions of the Mined Land Reclamation Act(Section 34-32-120,C.R.S. 1984,as amended)as determined through a Board <br /> finding. <br /> 4. 1 understand that statements in the application are being made under penalty of perjury and that false statements made herein are <br /> 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,C.R.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 modified form <br /> and subject the operator to cease and desist orders and civil penalties for operating without a permit pursuant to section 34-32-123, <br /> C.R.S. <br /> Signed and dated this 1�'- day of <br /> Colorado Legacy Land If Corporation Attest(Corporate/County Seal) <br /> Applicant/Operator N,(ne <br /> Signature: By: <br /> n /� Corporate Secretary or Equivalent <br /> Title: I V'a a g g Partner Town/City/County Clerk <br /> State of C LA Q6 2 d,0 ) <br /> ss. <br /> County of L cc.n f qk r 1 <br /> The foregoing instrument was acknowledged before me this day of A,ko t't a a <br /> by3g&S1 of rowadp 41�"A <br /> �WA�W <br /> E <br /> JOHNSTONERY PUBLIC Notary Public <br /> F COLORADO <br /> ID 20174042066 M Commission ex ires:XPIRES OCTOBER 10,2021 Y p <br />