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SIGNED, SEALED AND DATED this day of , Q Q I <br /> 1 I?�iJ n D t' �/aLioJb!/r9 V <br /> Operator (SEAL ` <br /> By: <br /> Title: <br /> NOTARIZATION OF OPERATOR'S ACKNOWLEDGEMENT <br /> STATE OF 0A(0 ) <br /> ss.: <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this O�`�---aa y of <br /> by ash©lam" of - \©�-O\ <br /> CARRIE HARTWELL 1 <br /> NOTARY PUBLIC Notary Public <br /> STATE OF COLORADO ` <br /> NOTARY ID# 20114046185 My Commission Expires <br /> MY COMMISSION EXPIRES JULY 21.2019 <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 /> Rev.05/12 <br /> - 3 - <br />