2016-03-04_REPORT - M1999073

• Permit No: M1999073
• IBM Index Class Name: Report
• Doc Date: 3/4/2016
• Doc Name: Annual Fee, Report & Map
• From: Pit 1
• To: DRMS
• Annual Report Year: 2016
• Email Name: LJW
• Media Type: D
• Archive: No

Agreement to Conduct Permitting by Electronic Means
Name of permittee representative desiring to
opt in to ePermit:
Name of permittee:
Title:
Signature:
Email Address for ePermit Account:
Notarized Affidavit of Signature
STATE OF: )
COUNTY OF: ) ss.
The foregoing instrument was acknowledged
before me this day of by
(date) (year)
as
(Name of permittee representative) (title)
of
(permittee)
NOTARY PUBLIC
(seal)
My Commission expires:
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