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RECFIVED <br />Agreement to Conduct Permitting by Electronic Means JUL 0 8 2016 <br />DIVISION OF RK AMATION <br />MINING AND BAFETY <br />Name of permittee representative desiring to <br />opt in to ePermit: 1t 1W <br />Name of permittee: _ 6j1ZjE1 CY400 f <br />Title: <br />Signature: <br />Email Address for ePermit Account: !�1% <br />Notarized Affidavit of Signature <br />STATE OF: ) <br />�tD'I`O <br />COUNTY OF: ) ss. <br />The foregoing instrument was acknowledged <br />before me this C` i. day of by <br />(date) (year) <br />as <br />1 tee representative) (title) <br />ROTARY PUB <br />(seal) <br />My Commission expires: <br />WIN WMTOUL <br />E <br />PWLIC* STATE OF CDLWW <br />Identdieition I� N154M700 <br />MSSian Expires W3W2o14 page 3 of 4 <br />