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Agreement to Conduct Permitting by Electronic Means ROSENE® <br /> FEB 2 3 2016 <br /> IDWISION OF RECLAMATION <br /> Name of permittee representative desiring to � �' MINING AND SAFETY <br /> opt in toePermit: Linda G. DeRose <br /> Name of permittee: Moffat County <br /> Title: <br /> Manager, Moffat County Road Department <br /> Signature: <br /> Email Address for ePermit Account: 1 derose0moffatcounty.net <br /> Notarized Affidavit of Signature <br /> STATE OF: COLORADO ) <br /> COUNTY OF: ) ss. <br /> MO FFAT <br /> The foregoing instrument was acknowledged <br /> before me this 1-7 _ day of by <br /> (date) (year) <br /> as <br /> Linda G. DeRose Manager, Moffat County Road Department <br /> (Name of permittee representative) (title) <br /> of <br /> Moffat Countyi�,,��e� <br /> (permittee) <br /> NOTARY PUBLI <br /> TAMARA J=AUGUST <br /> NOTAR <br /> STATE OF <br /> NOTARY ID <br /> MY COMMISSION EXP <br /> (seal) <br /> My-Commission expires: <br /> Page 3 of 4 <br /> l <br />