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Certification: <br />As an authorized representative of [he applicant, I hereby certify [hat the operation described has met the minimum requirements of the Following <br />terms and conditIoas: <br />1. This mining operation will not adversely affect the stabr7ity 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/operarornnd <br />the persons having an interest in the structure that damage to the structure is ro be compensated for by the applicant/aperator <br />(Section 834-32-115(4)(d), C.R.5.1984, as amended), then training may occur within 200 feet. Proof ofan agreement must be submitted <br />ro the Office prior to the decision date.) <br />2. No rmning operation will be located on lands where such operations are pmlubitedby law(Section 34-32-115(4xf), C.R.S. 1984, <br />as amended); <br />3. As the applicant/operator, I donot have anymining/prospecting operations in this state of Colorado currently is violation of the <br />provisions of the Mined Land Reclamation Act (Secti0on 34-32-120, C.R.S.1984, as amended) as detecmiaed through a Board fording. <br />4. I understand that statements in the application are being made umierpenalty ofperjury and that false statements madeherein are <br />punishable as a Class 1 misdemeanor pursuant ro 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 3C-32-1f2,GRS, ajthe Minedland Reclamation <br />Act Any alteration or modifuadon ojthk jorm shall resuU to voiding any permit ksued on the altered or modifred form and subject the <br />operator to cease and d¢sist orders and civil penalties for operating without a permu pursuant to section 34-32-123, C.RS. <br />Signed and dated this ~ day of tl7~(s'trf~~ ZdOla <br />oG c/~FjvT9~ l'/G, ai~i9 ~ /sl/G, <br />App$cart/Operator or Cotttpany Name <br />Signed: ~--~.~ <br />Title: V~r~~ ~izf-~~D,~~'T <br />State of ~~^'1O ~ - °°. ~ <br />Q~~ )ss. <br />County of ~~~`- 1 <br />If Corporation Attest (Seal) <br />~`~ <br />~ <br />~ ,. <br /> a <br />. q <br /> <br />^ <br />~~ A . <br /> <br /> <br /> <br />Signed: <br />Corporate Secretary or Equivalent <br />Towa/City/County Clerk <br />The foregoing instrument was acknowledged before me this ~ day of ~~GLcI Jim a`- <br />by ~Y'^~`7~' F'w'~- /~~Y~ as y,GG2. /.~'1g~ of ~~~ C~[.t' . <br />- ~kCl ~ I~ <br />`~~`' --;_; Notary Public ```\\\`,~YtS.PgT~i'i <br />~; ~ MyComn»ssionexpires~ .~..-_'::':••.- J~. <br />_.. _ y. . <br />- - __ : } _~ r rat : N ~_ <br />SIGNATU1Zl7S MUST BE IN;I3LUE LNK = o""~'w,-oo6 ~ <br />MiMIIJUiDC~MINPORMSUb23HItl2.APP (OSR62004) - -_ ,,,~, ~ • <br />1 <br />