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<br />9 (Form 1 - f1.11 information for DBMS use and confidential filing) <br />VIII. SIGNATURE REQUIREI'IF,NT <br />Please place you initials on the line provided: <br />.____ ~/ I hereby verify that the foregoing information is true and accurate and commit to the reclamation of the <br />aforementioned prospecting site as required by the Colorado i4iined Reclamation Act and the rules as specified in the <br />hard Rock'Vletal. Mining Rules and Regulations and this NOI forn~. <br />,_-/"~ - I: have enclosed the required permit fee. <br />__,,,~'~ I authorize ilte Division to contact and copy the 13LM and:~or USFS on any correspondence related to the prospecting <br />operation, if the prospecting operation is Eocated on federal public land. <br />__ I have also enclosed the appropriate reclamation surety amount or will post an amount as determined by the ot~ce, <br />based on the projected costs of reclamation. <br />____~ I understand that I am not authorized to create any surface disturbance until the surety amount is posted and approved <br />in writing from the Division of Reclamation, Mining and Safety. <br />_____,,,,~accept and agree to comply with the foregoing terms and conditions and with all of the provisions of Rules 3 and 5, <br />and C.R.S. 34-32-t01. <br />Thu form has been approved by the Mined Land Reclamation Board pursuant to section 34»32-113, C.R.S., of the Mined Land <br />Reclamation: Act. Any alteration or modification of this form shall result in voiding any NOI issued on the altered or modified <br />form and subject the operator to cease and desist orders and civil penalties for operating without a NOI pursuant to section 34- <br />32-123, C.R.S. <br />I, the undersigned, bein tt~;_ ie NOI holder or the person authorized to sign on behalf of the h1QI holder, declare that the information <br />given in this NOI form is true and correct <br />SIGNATURES MUST BE IN BI;UE INK <br />Signed and dated this ~~_ day of ~ _ c'~~, <br />Signature of NOI holder or. person authorized to sign: <br />~an7e{typed or print} .....~~'l.-f.'.l._..._!~-~=-W__~.!!~Ei~ _- ------.._. <br />_ .. ... _ <br />Q ......_.....---- ~ q <br />7'itle/I?osition: ,_....._...__~I.rp S G~~Gt~..._....._~...... __._ ......................_. A/t~l~ ~ [.C~ <br />- '_ <br />~.t~n6~JC~~pa~y <br />l ~Fn%rs ~~~re`_*'Sl~,zrr~~} ~-2~_1r1._.~sf~5r~?sil?rU~~?=?'n~.l~%!~3~4?r~?C)_'=_.l'_;.ct~t%~~tln~ t1~s_! F?laiCi' <br />_ ~, <br />