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<br />~~ <br />PEttIv1IT APPLICATIOtd <br />1~. The lands Herein do not affect any <br />of the lands dexribed in <br />Sri tion 115(4)(f) of the Mined <br />Land Reclamation Act (Specify <br />affirmation) <br />Ai'Yirniative <br />To the best of my knowledge, all the information presented in <br />this Application is true and correct. <br />~J a ~ <br />a <br />Title: <br />(Signature by individual legally <br />authorized w bind the operawr w <br />this Application.) <br />- J - <br />