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<br />? i <br />9 (Form 2- Public) <br />VIII. SIGNATURE REQUIREMENT <br />Please place you initials on the line provided: <br />K 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 Mined Reclamation Act and the rules as specified in the <br />hard Rock/Metal Mining Rules and Regulations and this NO] form. <br />I`_... I have enclosed the required permit fee. <br />_11_l? _ I authorize the Division to contact and copy the BLIvt and/or USFS on any correspondence related to the prospecting <br />operation, if the prospecting operation is located on federal public land. <br />t^._ I have also enclosed the appropriate reclamation surety amount or will post an amount as determined by the office, <br />based on the projected costs of reclamation. <br />K 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 />C\,? I accept and agree to comply with the foregoing terms and conditions and with all of the provisions of Rules 3 and S, <br />and C.R.S. 34-32-101. <br />This form has been approved by the .'dined 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 NUI issued on the altered or modified <br />form and subject the operator to cease and desist orders and civil penalties for operating without a N01 pursuant to section 34- <br />32-123, C.R S <br />I, the undersigned, being the NOT holder or the person authorized to sign on behalf of the NQ[ holder, declare that the information <br />given in this NOI form is true and correct. <br />SIGNATURES MUST BE IN BLUE INK <br />Signed and dated this. r _ Z: day of ?0 <br />Signature of NOI holder or person authorized to sign: <br />-game (typed or print) <br />i itlelPosition: _.. f2 © r T <br />. ..... ?( .__.___._. _ _..._a ..... _ ............ _.._.......... <br />I %,W.n''ahaw"Nsformd'i (t.'.:. ._v f r l'rs,s x =ins c??y 3'?:US 1?rc3srtc air APP.1j2-/-A;c1' <br />