2016-12-28_GENERAL DOCUMENTS - M2009035

• Permit No: M2009035
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 12/28/2016
• Doc Name: Agreement to Conduct Permitting by Electronic Means
• From: M.A. Concrete Construction
• To: DRMS
• Email Name: SJM
• Email Name: SLB
• Media Type: D
• Archive: No

o Conduct Permitting b Electronic Means c
A r ent t S Y © DEC 2 $2016
oa
DIVISION OF RECLAMATION
MINING&SAFETY
Name of permittee representative desiring to
opt in to ePermit: nI \
Az-c(2k r("0.
Title: f 2 S i c e-n �-
Name of permittee: M �? �' t .
u.c, 10 n -�-
Signature:
ePermitting Administrator(if different from
representative signing agreement) }
Email Address for ePermit Account: .- {j r e 5 n ct.n . h
Notarized Affidavit of Signature
ature
STATE OF: �� (A
)
COUNTY OF: ) ss.
The foregoing instrument was acknowledged
before me this day of �� [' .. by
(date) (month) (year)
as '"�--�w V\KC �� � t �� Ace:\
(Nalne of permittee representative) j (title)
of
TERESA K. HALL 4 (permittee)
NOTARY PUBLIC j
STATE OF COLORADO
NOTARY ID#20164026677 r
My Commission Expires July.14,2020
OTARY PUB IC
(seal)
My Commission expires:
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