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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 />1. This mining operation will not adversely affect the stability of any significant, valuable and permanent man-made <br />structures} located within nvo hundred (200) feet of the affected lands. (However, where there is an agreement between the <br />applicanubperator and the persons having an interest in the strucmre that damage to the structure is to be compensated far by <br />the applicant/operator (Section 34-32-115(4)(d), C.R.S. 1984, as amended), then mining may occur within 200 feet. Proofof <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 34-32-1 I5(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 of the provisions of the Mined Land Reclamation Act (Section 34-32-120, C.R.S. 1984, as amended) as determined <br />through a Soard finding. <br />4. I understand Yhat sretemenk in the application are being made under penalty of perjury and that false statements made <br />herein are punishable as a Class t 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 34-32-111,C.R.S., ojthe Mined Land <br />Reclamatiox Act Any alteration os modification ojthis form shall result in voiding any permit issued on the altered or modified <br />form and subJect the operator to cease and desist orders wnd civil penalties for operating without a permit pursuant to <br />section 34-32-123, C.R.S. <br />Signed and dated this ~9 ~~ day of~/ 2DD~ <br />i~P.UISd,/ ////./PS ~~/s.9 ~~aeO • If Cotporation Attest (Seal) <br />AppiicariUOperator or Companytame <br />`,Signed: `~ Signed: _.____ <br />,;: _ , <br />=_ T : rr~ ` /C =. ~~ ~~/ ~ / Corporate Secretary or Equivalent <br />~=Title: L~>c[~NY'i~P~` t/iCC ~st/p..T - Gl --5. ~P2'a~/v~/s Town(City/County Clerk <br />State of I d ~04 <br />ss. <br />County of -~~~~ ___) <br />The forego`i~n~g~ i~n~st/ru~mentnwaspackn/o_w~edged before me this ~~ day of ~ , _, <br />by ___~~~'~L-Cf-K /.d K!~/~' $ as 1/~~Y~_~i+~t`r(~t~of~ <br />ijJ <br />SIGVATURES ML;ST RB I~ SLUE INK <br />~r~~~ i <br />.-d!minlf3DC7MINF'OR~7S\HRI?.MP.dce (06/!i/2007) ~~3~ - <br />iaiy ~._ <br />