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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the following <br />terms and conditions: <br />1. This mining operation will not adversely affect the stability of any significant, valuable and permanent man-made structure(s) located <br />within two hundred (200) feet of the affected lands. (Ilowever, 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 the applicant/operator (Section 834-32-115(4)(4), <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 located on lands where such operations are prohibited by law (Section 34-32-115(4)(f), C.R.S. 1984, as <br />amended); <br />3. As the applicant,'operator, I do not have any mining/prospecting operations in this state of Colorado currently in violation of the provisions <br />of the Mined Land Reclamation Act (Section 34-32-120, C.R.S. 1984, as amended) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty ofperjury and that false statements made herein are punishable <br />as a Class 1 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 pursuantto section 34-32-112,C.RS, ofthe Mined Land Reclamation Act. <br />Any alteration or modification of this form shall result in voiding any permit issued on the altered or modifred form and subject the operator to <br />cerise and desist orders and civil penalties for operating without a permit pursuant to section 34-32-123, CR.& <br />Signed and dated this day ofA1J&n-"tm. <br />If Corporation Attest (Corporate/County Seal) <br />Applicant/Operator Name <br />Signature: <br />171) / W e?11Ce%? <br />Title: <br />State of ulazJoi <br />County of <br />TowniCity/County Clerk <br />) ss. <br />Corporate Secretary or Equivalent <br />_.3?-....__, Q_0, <br />The foregoing instrument was acknowledged before me this ?_ clay of' <br />bylas -- of 'CPFtY PU? <br />r.•' ?cl <br />RHONDA L. <br />HARRIS r <br />OF <br />Notary q Public <br />My Commission expires. <br />__.._... <br />My Commission Expires 04105108