2012-12-12_REVISION - P2010026 (3)

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VIII. SIGNATURE REQUIREMENT Please place you initials on the line provided: &iP Nano (typed or print) Title/Position: 9 (Form 2- Public) I hereby verify that the foregoing information is hue and accurate and commit to the reclamation of the aforementioned prospecting site es requited 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 tho Division to contact and copy the I3LM and/or (BPS on any correspondence related to the prospecting ) operation, if the prospecting operation Is located on federal public land. /(�/ I have also enclosed the appropt'iato reclamation surety amount or will post an amount as determined by the office, based on the projected costs of reclamation, if w 1 understand that 1 ant not authorized to cre-ato any surface disturbance until the surety amount is posted and approved in writing fioni the Division of Reclamation, Mining and Safety. I accept and agree to comply with the foregoing tenns and conditions and with all of the provisions of Rules 3 and 5, and C.R.S. 34 -32 -101, This farm Inns been approved by the Mined Land Reclamation Board pursuant to section 34-32-113, CAS., of the Mined Land .Reclamation Act, Any alteration or modification of this form shall result in voiding any NOI Issued on the altered nr modified form and subject the operator to cease and desist orders and civil penalties for operating without a NOIpursuant to section 34(- 32-123, C.R.S. J. the undersigned, being the NOI holder or the person authorized to sign an behalf of the NOI holder. declare that the information given in thls NOT form is true and correct, SIGNATURES MUST BE IN BLUE INK Signed and dated this of it- off , 0 0 , Signature of NOI holder or person authorized to sign: f g1A tre t roctr.Le.: r.cv% G r5 L' Amin ls re fornls`77•07.01 'sallb u : asptoinG fonrisJO1 }'respeciina App D1/24/