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Agreement to Conduct Permitting by Electronic Means <br />Name of permittee representative desiring to <br />opt in to ePermit: <br />Name of permittee: <br />Title: <br />Signature: <br />Email Address for ePermit Account: <br />STATE OF: <br />COUNTY OF: <br />RECEIVED <br />.inns 2 6 2016 <br />DIVISION OF RECLAMATION <br />MINING AND SAFETY <br />:Y7_rl' Fa Cher <br />L.DUgiZIVI <br />Viz:'� 41l�P <br />rf- <br />Notarized Affidavit of Signature <br />(0 I 0I; tc) <br />ss. <br />The foregoing instrument was acknowledged �� <br />before me this _ 1'0 day of NYl t,u,v) L , 2..OI t (4 by <br />(date) (month) I (year) <br />as <br />7 f'. t•—""mac l'^ //. f. <br />(Name of permittee representative) (title) <br />JOAN E. HORST <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 19944018%67 <br />'Y COMMISSION EXPIRES NOVEMBER 21, 2015 <br />(seal) <br />My Commission expires: <br />of <br />KN <br />f <br />L -D th 'CLC 1l\w .0(.1(1\i 2 RC <br />(permittee) <br />4tN) U'/C)'1&(' <br />NOTARY PUBLIC <br />Page 3 of 4 <br />