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RECEIVED <br /> Agreement to Conduct Permitting by Electronic Means <br /> FEB 2 9 201 r? <br /> 616( Division of Reciamation, <br /> Name of permittee representative desiring to Mining&Safety <br /> opt in to ePermit: <br /> Title: <br /> Name of permittee: La o�1 <br /> .. <br /> Signature: <br /> ePermitting Administrator(if different from <br /> representative signing agreement) <br /> Email Address for ePermit Account: <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> COUNTY OF: ) ss. <br /> The foregoing instrument was acknowledged <br /> before me this a�Z day of by <br /> (date) (month) (year) <br /> as <br /> (Name permittee repr entative) (title) I <br /> of A .� - 7� .L <br /> EENotary <br /> (permitted)cole Thomasotary Publicte of Colorado <br /> ID 20124031891N TARY PUBon Expires July 19,2016 <br /> (seal) <br /> My Commission expires: <br /> Page 3 of 6 <br />