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Certification: <br />As an authorized representative of the applicant. I hereby certify that the operation described has met the minimum requirements ofthe following <br />teens and conditions: <br />I Phis mining operation will not adversely, affect the stability of any significant, valuable and permanent man-nwde structure(s) located <br />within two hundred (200) feet ofthe affected lands. (However, where there is an agreement between the applicanGopcrwor and the persons <br />having an interest in the structure that damage to the structure is to be compensated fir by the applicant operator (Section 834-32- l 15(4)(d). <br />C.R.S. 1934, as amended), their 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)(1), C.R.S. 1934, as <br />amended): <br />3. As the applicia, 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. 1934, as amended) as determined through a Board fin im <br />4. I understand that statements in the application are being made unifier penalty ofperlury and that false statements made he;rin are punishable <br />as a Class 1 misdemeanor pursuant to Section 18-S-503, C.R.S. 1984, as amended. <br />ct. <br />This fount has been approved h1, the Mined Lanz! Reclamation Board pursuant to seclion 34-32-112,0. R.,S., of the Mined Lanz! Reclamation Ac/. <br />Ant, alteration or modification o f this. form shall result in voiding anY permit issued on the altered or modified form and suhject the operator to <br />cease and desist orders and civil penalties for operating without a permit pursuant to ,section 34-32-123, C.R.S. <br />Signed and dated this ___ day of._ <br />13 Y.- C"St/ ' <br />? y: CIA cA- L11 L 1 H " d 6F2 <br />? <br />1 If Corporation Attest (C orporaterCounty Sea]) <br />Y4ppli,ant,'LOperator"Nailie <br />Signature: By: <br />Corporate Secretary or Equivalent <br />Title: - 'Town-City/County Clerk N11 uC! <br />` 1 <br />State of o l NOTq??'':?? <br />ss <br />County of pUeLIC <br />0 <br />0LO?' x\\`?? <br />?1 O O <br />?l e ?tCt \ <br />fhe foref,!orng instrument was ackno%%ledged before me this uav of i/ <br />by as ?AhaGVf of <br />aa/vk(L <br />Notary Public <br />My Commission expire.: ? '?uaY? 1/?t (cQ-1