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~- <br />Certification: <br />As an authorized representative of the applicant, l hereby certify that the operation described has met the minimum requirements of the following <br />terms and conditions: <br />1. This tnining operation wiil not adversely affect [he stability of any significant, valuable and permanent man-made structure(s) located <br />within bvo hundred (200) fee[ of the affected lands, (However, where there is an agreement between the applicantroperator and the persons <br />Laving an interest in the stntcture that damage to the s4ucture is to be compensated for bythe applicant/operator (Section 834-32-I I5(4)(d), <br />C.R.S. 1984, as amended), then mining may 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 [geared on lands where such operations are prohibited by law (SecSon 34-32-115(4)(f}, C.R.S. 1984, as <br />amended); <br />3. As the applicanUoperator, I donor have any mining(prospectinggperations in this state ofCotorado currently in violation ofthe provisions <br />of the Mined Land Reclamation Act (Section 34-32-120, C.RS. 1984, as amended) as determined through a Boazd Ending. <br />4. 1 understand that statements in the application aze being made under penalty ofperyury and that false statements made herein are ptmishable <br />as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS, t984, as amended. <br />This form bas been approved by the Mined Land Reclamation Boardpursuant to seetton 34-32-112,G:RS., ojthe bfinedGandReelamationAct. <br />Any alteration or modification ojtltis jorm shall resuU in voiding anypermit issued on the altered or modifted form and subject tlee operatortn <br />cease and desist orders and civil penalties jar operating tvkbout a permit pursuant to section 34-32-123, C.R.S. <br />Signed and dated this ~~ day of .~ ~ (- ~ ~.c~7 <br />_.~zV2 ~kzlS ~eso.,aCrS ~, rp ( ~ ty ) <br />~`"~ cJ?If Co orntion Attest Co ratelCoun Seal <br />ApplicanUOperator Name <br />Signa ; ~... A' By. S ~ ~ ~n .ti.a.a ~ ~~ <br />EV CJ $ ~ Corporate Secretary or Equivalent <br />Title: ~ ° ~ L'F~=G `n> u 2l Town'CityiCounty Clerk <br />State of ~ lDL''(~~) <br />County of 1; ~1%t~ <br />ss. <br />~ 2« <br />The foregoing insitvntent was acknowledged before me this ~ day of ju\~ ~ <br />`~~~ ash- of ~ tit~~:.z_~S ~ s~~nc;._S ~, a~~~.~. ~z~ <br />~~zc~..+-..~ V.(? ~` Ct~~~oG~~^=~ bpi-13c}GL Ly~c,C,kc~A~rt1 <br />~ Tom` ~~ . Notary Public <br />My Commission expires:~~ ~~dD`~ <br />MaMINLSNAREIVSFORMS12823FDM0.! 12 (05!2&'OS) <br />