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r' RECEIVED <br /> Agreement to Conduct Permitting by Electronic Means <br /> JUN 24 2016 <br /> DIVISION OF RECLAMATION <br /> Name of permittee representative desiring MINING&SAFETY to c <br /> opt in to ePermit: LQ 1..)��✓1G 2 1 it?ke. <br /> Name of permittee: Z�Q,ia,d o �l�rJt+'►et �o��u-�►c� <br /> Title: Direr T'G ae 5���5 C/oSurL� r��e��,TiDr� <br /> Signature: <br /> Email Address for ePermit Account: <br /> �a <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> COUNTY OF: ) ss. <br /> The foregoing instrument N,as acknowledged <br /> before me this day of by <br /> (date) () ar) <br /> as <br /> LAi�� �GF �sk� �c� T <br /> (Name of permittee representative) (title) <br /> of �ArzAfld / 41 t.If J <br /> (permittee) <br /> NOTARY PUBLIC <br /> (seal) r,z..,,..._.,.... ,SO <br /> My Commission expires: - ra ' �:-OT y •;2 <br /> Page 3 of 4 <br />