I,  (landowner) certify that I hold the surface rights on the (common name of Pit) Pit located in the (¼¼ Section description) of Section No. , T. R. the 6th Prime Wind River Meridian, in Albany Big Horn Campbell Carbon Converse Crook Fremont Goshen Hot Springs Johnson Laramie Lincoln Natrona Niobrara Park Platte Sheridan Sublette Sweetwater Teton Uinta Washakie Weston County, Wyoming.

I further state that (operator) has fulfilled its commitment to reclaim the above mentioned land to my satisfaction and according to my understanding of the Wyoming DEQ/LQD approved Mine and Reclamation Plans under (type of permit) . Permit No. . I believe the reclaimed lands are capable of supporting the current use of the land for [list land use(s)] .

Dated this day of  January February March April May June July August September October November December , 2009 2010 2011 2012

Remarks: May include such entries as:

1. Notation of on site specific reclamation procedures such as reconstruction of an irrigation canal or reclamation to a hayland, etc.

2. Notation of material stockpiles which will be at the landowner's request for his/her use.

3. Notation of, and specific identification of any mining-related roads which the landowner wishes to remain for his/her use.