Laserfiche WebLink
Agreement to Conduct Permitting by Electronic Means <br />Name of permittee representative desiring to <br />opt in to ePermit: <br />Title: <br />Name of permittee: <br />Signature: <br />ePermitting Administrator (if different from <br />representative signing agreement) <br />Email Address for ePermit Account: <br />STATE OF: <br />COUNTY OF: <br />Colorado <br />Jason Burkey <br />RECEIVED <br />FEB (i 12016 <br />DMSION (1r . 'CUR/RATION <br />MINING Arm SAFETY <br />Environmental/Resource Manager <br />Oldcastle SW Group, Inc. dba Telluride Gravel <br />Peter Siegmund <br />jburkey@oldcastlematerials.com <br />Notarized Affidavit of Signature <br />Mesa <br />The foregoing instrument was acknowledged <br />before me this <br />day of January , 2016 by <br />(date) (month) (year) <br />as <br />Jason Burkey Environmental/Resource Manager <br />(Name of permittee representative) <br />(seal) <br />My Commission expires: <br />(title) <br />of Oldcastle SW Group, Inc. <br />dba Telluride Gravel <br />(permittee) <br />Page 3 of 6 <br />NOTARY PUBLIC <br />