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SIGNED, SEALED AND DATED this �� day of <br /> Operator (SEAL) <br /> By: <br /> Title: „___ Il1/tkrJpls�il` <br /> NOTARIZATION OF OPERATOR'S ACKNOWLEDGEMENT <br /> STATE OF ) <br /> � ss.: <br /> COUNTY OF <br /> The foregoing instrument was acknowledged ore 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 /> ivi on erector <br /> Rev.05 12 <br /> - 13 <br />