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• .1,greernent to Conduct Permitting ht' Electronic ;1leans. <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 />S'I'A'1'I; OF: <br />C'Ot INTY OF: <br />L Ji- 90.s <br />Gr'L�1 JL <br />rne,; i-5 2N Mme') CSM <br />Notarized Affidavit of Signature <br />rc4-00 <br />"I'he foregoing instniment was acknowledged <br />before nie this <br />\C u Lest-tr <br />) <br />(Name of permittee representative) <br />ERIN MUMMA <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID # 20124054708 <br />MY COMMISSION EXPIRES AUGUST 22 2016 <br />(seal) <br />My Commission expires: <br />7?ido-lico <br />ss. <br />day of <br />RECEIVED <br />FEB 0 2 2016 <br />DIVISION OFRECLAMATION <br />MINING AND SAFETY <br />(date)—Icin;A,CAA1 (year) <br />aN <br />of <br />by <br />cxir E -t (�o((to(J V Ism t <br />(title) <br />¶-ve(4 !,J1,cc-F-etl S <br />(permittee) <br />Page 3 of 4 <br />NOTARY Pt MIR' <br />