PERMIT FILE - 6/23/2009, 8:17:24 AM-MR1

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9 (Form 2- Public) VIII. SIGNATURE REQUIREMENT Please place you initials on the line provided: I hereby verify that the foregoing information is true and accurate and commit to the reclamation of the aforementioned prospecting site as required by the Colorado Mined Reclamation Act and the rules as specified in the Hard Rock/Metal Mining Rules and Regulations and this NOI form. I have enclosed the required permit fee. I authorize the Division to contact and copy the BLM and/or USFS on any correspondence related to the prospecting operation, if the prospecting operation is located on federal public land. I have also enclosed the appropriate reclamation surety amount or will post an amount as determined by the office, based on the projected costs of reclamation. 1 understand that I am not authorized to create any surface disturbance until the surety amount is posted and approved in writing from the Division of Reclamation, Mining and Safety. I accept and agree to comply with the foregoing terms and conditions and with all of the provisions of Rules 3 and 5, and C.R.S. 34-32-101. This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32-113, C.R,.S, of the Mined Land Reclamation Act Any alteration or modification of this form shall result in voiding any NOI issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating without a N01 pursuant to section 34- 32-123, C R.S. I the undersigned being the NOI holder or the person authorized to sign on behalf of the NOI holder, declare that the information given in this NOI form is true and correct. SIGNATURES MUST BE IN BLUE INK Signed and dated this day of , Signature of NOI holder or person authorized to tgn: Name (typed or p ' t) ` lc ?O Title/Position: M:1minlsharelvsforrns107-07-01 vsforrnskProspecting formANO[ Prospecting Apo. 07/24/07