2017-03-09_REPORT - M1998034 ‎(2)‎

• Permit No: M1998034
• IBM Index Class Name: REPORT
• Doc Date: 3/9/2017
• Doc Name: Annual Fee/Report/Map
• From: Mountain Park Concrete, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: PSH
• Media Type: D
• Archive: No

Agreement to Conduct Permitting by Electronic Means
5. Affiant will inform the Division of Reclamation Mining and Safety within thirty
(30) days in the event that his/her authorization to execute ePermitting Documents
on the Company's behalf is terminated.
Further, Affiant sayethhnnot. ('
Affiant's name
ignatur
Notarized Affidavit of Si ng a
STATE OF: )
ra kb
COUNTY OF: ) ss.
The foregoing instrument was acknowledged
before me this day of by
(date) (month) (year)
C
as
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(Name of permittee representative) (title)
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(permittee)
CtATE
IN NOY 2000 NOTARY PUBLIC c
MY CISSION SS
(seal) }
My Commission.expires: CATHERINE S.ACORD
h NOTARY PUBLIC
6(1� 0STATE OF COLORADO
MY COMMISSION E(IPIRES SE 19,2MD
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