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SIGNED, SEALED AND DATED this day of , <br /> Operator (SEAL) <br /> By: <br /> Title: <br /> NOTARIZATION OF OPERATOR'S ACKNOWLEDGEMENT <br /> STATE OF ) <br /> ss.: <br /> COUNTY OF ) <br /> The foregoing instrument was acknowledged before me this day of <br /> by as of <br /> Notary Public <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 /> Rev. 05/12 <br /> - 3 - <br />