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9 <br />~~lll. St(:\.4TfNF: RFC)l'1l2F~1FtiT <br />Pleas< place ~~ou initials on the line provided: <br />~_ I hereby veriti that the t-ot•<<~uing information is true and accurate and cumntit te> <br />aforementioned prospectin~> site as required b~• the Colorado Mined Rec(arnation :let and thetnrles a la~peciitlcd~n f~e <br />~~~j Hard Rack. tiletal i~tinina Rules end Ke~ulatiiuts and this ti01 tbrm. <br />~~SL__ I have encloseii the regttired perrttit tee. <br />_-,~~~ t authorize the Division to contact and cope the 8~M andlor LSf='S on anv correspondence related to the pr•ospecrins <br />nnN r~~t tf)n if tit_r l)r.? n~rrinu ,~ini•ratinn is )ri~•~tr,ri nn fwtlL~r~l rv ~h)i,• la ii{ . <br />~. .1..•. <br />~~ i have also enclosed the appropriate reclamation surety amount or ~~•ill post an amount as deter-rnined by the ot~lice. <br />- -_- ~ t?aced on the projected costs vi reclamation. <br />/l~~-~- (understand that ! am not audaorized to ct•eatc anv surface disturbance until the suret_~~ amount is posted and approve-d <br />rn writing from the Division crt fte,clamation. Mining and SaPrty, <br />_/~~~'' I accept rrnd agree to comply with the fore_oins terms and conditions and with all of~the provisions of Rules 3 and ~. <br />and C.R.S. ,4-32-101. <br />7b/s furnr leas heen upprur•ed ht• the AI/ned Land Rcc•lamatiun Buu~d puxcururl ~u .cec•tiun 34-_i2-1 /3.C:R.S., of the :Flined /_and <br />Rer/mnavinn ,-I cr. .•1r-t• a/rerutinrr ur mudrficaNurr of t/tic form s/ra// result in vuirling anti a'O/ issuer! uu !hc ahercd or nrur/ified <br />firrm rrnd subject the nperalur a, cease anti de.~•is! ordecc urrd ci-•/l penalties fur operrrlhr~ without a ,VOI purcuunt to .cectinrr 34- <br />3?-123, C: R.S. <br />1. the undersi~_ned. Liein,> the_ti01 hplder_or the"Lerson authorized to sisn on hehalf of the \nl holder declare that the information <br />•~itien in this \OI form is n•uC and correct <br />SICtiATURES 17US"f Bit IN BLl'E iNK <br />r <br />Signed and dated this __~3 _~ _____ day in_ _.~~ <br />Sig,nature of NOI holder ar pe:rson authorized to sr~_n: <br />/~~° fly <br />'~=r ",.,,.t,ri~t~ Richard Blubaugh <br />rift :-. ..,,:~r~ V.P. EH&S Resources <br /> <br />