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RECEIVED <br /> Agreement to Conduct Permitting by Electronic Means <br /> FEB 0 5 2016 <br /> DMSION OF RECLAMATION <br /> Name of permittee representative desiring to YL41NG AND SAFETY <br /> opt in to ePermit: C <br /> Name of permittee: 4 C- Pr C1 �- S � <br /> o �c V\C <br /> Title: <br /> CAL JC' <br /> f -e <br /> Signature: <br /> r <br /> Email Address for ePermit Account: <br /> VV\C.O e,r\g na , qCa n rC)A(ACAS. COw� <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> o l o NO(c) <br /> COUNTY OF: ) ss. <br /> The foregoing instrument was acknowledged <br /> before me this q +" day of ,).otb by <br /> (date) (year) <br /> as .n <br /> (Name of permittee representative) (title) <br /> of <br /> (permittee) <br /> BETTY CRITES <br /> NOTARY PUBLIC <br /> STATE OF COLORADO NOT Y PUBLIC <br /> N&ARY ID; 19954006312 <br /> MY COMMISSION EXPIRES: APRIL 262019 <br /> (seal) <br /> My Commission expires: <br /> OLk^?I,0 "Z-olei <br /> Page 3 of 4 <br />