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Agreement to Conduct Permitting by Electronic Means <br />Name of permittee representative desiring to <br />opt into ePermit: 1 a <br />Title: <br />Name of permittee: CLA (--)I' a I j i� I <br />Signature: C�� ,,�rp <br />ePermitting Administrator (if different from <br />representative signing agreement) <br />Email Address for ePermit Account. C, So, r"A (' a I Im I sp J-1 41 A <br />OY�'� <br />Notarized Affidavit of Signature <br />STATE OF. ) <br />COUNTY OF: ) <br />The foregoing instrument was acknowledged <br />before me this Q day of <br />(date) <br />ss. <br />Aas <br />(Name of permittee representative) (title) <br />ALE7HEA FOSTER v. <br />Notary Public <br />Carbon County <br />Wyoming <br />Lu <br />y Commission Expires Jun 18, 2018 <br />(seal) <br />My Commission expires: <br />r j JY <br />roll <br />, o /7 by <br />(month) (year) <br />MWEd .', ' ► E1' <br />J� <br />TARY PUBLIC <br />Page 3 of 6 <br />