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-?- <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 />]. This mining operation will not adversely affect the stability ofany 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 />applicanVoperatorsnd the persons having an interest in the stmcture that damage to the stmcture is to be compensated for by <br />the appticantJoperator (Section 3432-115(4}(d), C.R.S. 1984, as amended}, then mining may occur within 200 feet. 1'roofof <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 34-32-1I5(4)(f), <br />C.R.S. 1984, as amended); <br />3. As the applicantJoperator, I do not have any mining/prospecting operations in this state of Colorado currently in <br />violation of the provisions of the Mined Land Reclamation Act (Section 34-32-120, C.R.S. 1984, as amended} as determined <br />through a Board fording. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements made <br />herein aze punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.R.S 1984, as amended. <br />This jorm has been approved by the Mined Land Reclamation Board pursuant to section 34-32-112,C.R.S., of the Mrned Land <br />Reclamation AM. Any alteration or modwfrcatian ojthis form shall result in voiding any permit Issued on the ahered or modified <br />jorm and subject the operator to cease and desist orders and civtl penalties for operating without a permh pursuant to <br />section 34-31-123, C.RS. <br />f~i <br />Signed and dated this z9 _ day of__ ///A/ OB 7 <br />~- <br />Applicanti~Ope/rator or Company Name <br />Signed: ~1/ <br />Title: ~jCPCaT'flrr. iiti !/lesr,(v~- U•~-~etwi`~u;~s <br />Stateof_~0/D/~1~0 ) <br />ss. <br />County of ~VC / ____} <br />If Corporation Attest (Seal) <br />Signed: ___-..__ - <br />Corporate Secretary or Equivalent <br />TowrJCity/County Clerk <br />The fore oing mstrument was/a'ckn/owledged before me this ~~ _ ~~,,d~ay~,o,~f l /~/ _ _~/ <br />by r ~ _~ ~ c n a_~S as _~'t/~ '[.-1CtCC! "_ (~- rXd'of ~ 6t~JV <br />SIGNATURES ML7ST RF. IN BhUE INK <br />r <br />M:~min\F3[X1~MINFORMSWRt?.A{'P.dce (06/ll2(N11} <br />