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9 (Form 2- Public) <br />VIII. tilk I t 1ty Ill:OI I1lI.'?N 11:.1T' <br />Please place you initials on the line provided: <br />I hereby yerifv that the foregoing intinnation is it-tic and accurate and commit to the reclamation of the <br />a l'orementioned prospecting site as required by the Colorado %lined Reclamation Act anti the rules as specified in the <br />I lard Rocl.'Mclal Minin>: Rules and Regulatiolts and this N( )I fiorm. <br />I have enclosed the required permit 1'ec ` <br />authorise the O'N isrorn to contact and copy the MAI and 'or t SFS on any correspondence related to the prospecting <br />operation. ship( prospecting operalion is located on tCdCrtl puhlic land. <br />have also enclosed life appropriate rcclantalion suref\ amount or wil post an amount as determined hN the office, <br />based on the projected costs oft cc lanial loll. <br />1 understand that I ant not authori/ed too create any surface disttu•hance until the surety amount is posted and appmycd <br />in writing from the Di\ision of Rcclamation. 'dining and Satcty. <br />I accept and agree to comply \\ fill the fioregoing terms and conditions and \% fill all of the pro\isions of' Rules ; and S. <br />and ('.R.S .11-4-321-101. <br />Thi% lor•mr has been approved hr the Mined Lund Reclamation Board pur%uanl to section 34-J2-1 13. C.R.S., of the Mined Land <br />Reclamation . Ict. . I nY alteration of- modification ol'this lorm sha11 result in voiding unr AO/ is:iued on the ahered or mrodijied <br />lOrmr and <ubje(t the operator to (ease and desist orders mod civil pc•rraltie c leer mperatirr, without it A01luus hint to section 34- <br />32-1:3, C.R.S. <br />L the undrrsiLnctl, hcin the \(11 holder or the Person authori/ed to sign on behalfof'the \OI holder, declare that tile ini'OrmallOll <br />Ok en in this \OI liornl is 11-ue and correct. <br />\I(.\ \ I I RI s, Nit s I BF IN MA I I\h <br />Signed and dated 11111 Zs day of <br />Signarturc of 01 holder or person aut orized to sign: <br />GC <br />\ameOypedor prim) <br />11110 1'0.11101: P4t*6 tll- <br />\I. nun-.h.irc`y,G+nn: U7-11°-trl csGnni,. l'ro.pccun, 6xms\u1 hoyccIml \p p u- 2 J u-