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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)located <br /> within two hundred(200)feet of the affected lands. (However,where there is an agreement between the applicant/operator and the <br /> persons having an interest in the structure that damage to the structure is to be compensated for by the applicant/operator(Section <br /> 834-32-115(4)(d),C.R.S. 1984,as amended),then mining may occur within 200 feet. Proof of an agreement must be submitted to the <br /> 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.1984,as <br /> 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 aBoard finding. <br /> 4. I 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 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 fo rm <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 ay day of /) (-C';,1 h(Ai-, )`f <br /> Grand Island Resources LLC If Corporation Attest(Corporate/County Seal) <br /> NC S< < / <br /> Applicant/Operator Name <br /> ;� <br /> Signature: 2 By: <br /> Corporate Secretary or Equivalent <br /> Title: ✓f C jpt e5 Town/City/County Clerk <br /> State of Neu, yv t t- <br /> )ss. <br /> County of NA-15'54 i1 ) <br /> The foregoing instrument was acknowledged before me this "2� day of b cC.0"113 t , 2 0%L. LP <br /> byPi4A..prrMint,c,4s )6447 of C.,/tM9/3iotA.� %Z�'sc ' �r'S� GLc, <br /> Notary Public <br /> My Commission expires: <br /> TAHMINA KHATUN <br /> o Notary Public,State of New York.NO.01 KH6309400 <br /> Qualified in Nassau County <br /> ommission Expires August 11, 20 <br />