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SIGNED, SEALED AND DATED this <br />-• day of <br />, • • <br />Operator <br />(SEAL) <br />(, <br />By: <br />Title: I, • , (1;c -k <br />NOTARIZATION OF OPERATOR'S ACKNOWLEDGEMENT <br />STATE OF ,{(t A <br />) ss.: <br />COUNTY OF \'1 <br />My Commission Expires <br />STATE OF COLORADO <br />DEPARTMENT OF NATURAL RESOURCES <br />MINED LAND RECLAMATION BOARD <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />By: Date Executed: <br />Division Director <br />3 <br />3 IH4, <br />Rev. 05/12 <br />