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!exti1ication; <br />:a an authorized representative of the applicant, r hereby certify that the operation described has <br />nt the minimum requirements of the following terms and conditions: <br />1. This mining operation will not adversely affect the stability of any significant, valuable <br />and permanent man -made structure(s) located within two hundred (200) feet of the affected <br />lands. (However, 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 <br />the applicant /operator (Section 834- 32- 125(4)(d), C.R.S. 1984, as amended), theta mining may <br />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 <br />(Section 34- 32- 115(4 }(f), C.R.S. 1984, as amended ); <br />3. As the applicant /operator, 1 do not have any mining /prospecting operations in this state <br />of Colorado currently in violation of the provisions of the Mined Land Reclamation Act <br />(Section 34 -32 -120, C.R.B. 1984, as amended) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury <br />and that false statements made herein are punishable as a C1aes 1 misdemeanor pursuant to <br />Section 18 -8 -503, C.R.S. 1984, as amended. <br />is form has been approved by the Mined Land Reclamation Board pursuant to section 34 -32- <br />2,C.R.B., of the lifted Land Reclamation Act. Axy alteration or modification of this form Waal.' <br />suit in voiding any permit issued on the altered or modified form and subject the operator to <br />sae and desist orders and civil penalties for operating without a peewit pursuant to section 34- <br />-123, C.R.B. <br />pied and dated this / <br />i41s / - e--`r DiAdte <br />Applic <br />[nature: <br />le: (2 iitSi tV ! &Ur- - /f, £ <br />to of C.6-.0 <br />foregoing instrument was acknowledged before <br />- 7 - <br />v <br />Byc <br />,4124:401.0 as gaSt/Yr•47 +� <br />rr` SH 3 \VS ORMS \2B33wpMo.112 (05/2e/04 <br />day of , o? Q O -6 . <br />re Corporation Attest (Corporate /County Seal) <br />Corporate Secretary or <br />Town /City /C <br />me this <br />/ <br />day Z 9 IQ <br />/140g-Y -4 ee A4 4 <br />My Commission expires. <br />KAREN KRAUSS o` <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />My Commission Expires June 4, 2008 <br />