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~ _ <br />Certification: <br />A9 an authorized representative of the applicant, I hereby certify that the operation described has <br />met the minimum requirements of the following terms and conditions: <br />1. This mining operation will not adversely affect the stability of any significant, valuable <br />and permanent man-made structure(s) located within two hundred (200) feet of the affected <br />lands. (However, where there is an agreement between the applicant/operator and the persons <br />having an interest in the structure that damage to the structure is to be compensated for by <br />the applicant/operator (Section 839 -32-115(4){d), C.R.S. 1984, as amended), then mining may <br />occur within 200 feet. Proof of an agreement must be submitted to the Office prior to the <br />decision date.) <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32-115 (4}(f}, C.R.S. 1984, ae amended); <br />3. Ae the applicant/operator, I do not have any mining/prospecting operations in this state <br />of Colorado currently in violation of the provisions of the Mined Land Reclamation Act <br />(Section 34-32-120, C.R.S. 1984, ae amended) ae determined through a Board finding. <br />4. Z understand that statements in the application are being made under penalty of perjury <br />and that false statements made herein are punishable as a Class 1 misdemeanor pursuant to <br />Section 18-8-503, C.R.S. 1984, as amended. <br />Thies form has been approved by the Mined Laced Reclamation Hoard pursuant to section 34-32- <br />112,C.R.B., of the Mined Laced Reclamation Act. Any alteration or modification of thin form shall <br />result in voiding any permit issued oa the altered or modified form and subject the operator to <br />cease sad deaiat orders and civil penal ti ea for operating without a pezmit pursuant to aectioa 39- <br />32-123, C.R.S. <br />Signed and dated this ~"wday of ^~ tv! ~/ a~~- <br />Signatnr <br />.Tit3e:,~.~ vu ~~~ CXl'~ <br />~- <br />SCaGe~ f U - ) <br />ss. <br />County of <br />.. <br />i. <br />If Corporation Attest (COrporatafAotlaty Seal} _^ <br />= r __ <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoipng instrument was acknowledged before me this ~(~d y of ~~___,o2i2® ~\ <br />by ~~ ~ as <br />My Commission expires: <br />M:\MIN\SHA[iS\VSFORMS\2B23FDM0.112 (05/26/04) <br />