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U� Agreement to Conduct Permitting by,Electronic Means RECEIVED <br /> �/( I qga JUN 19 2017 <br /> DIVISION 9`fXFBI <br /> Name of permittee representative desiring to MINING AJ r,t <br /> opt in to ePermit: <br /> Title: <br /> Name of permittee: <br /> Signature: k' <br /> ePermitting Administrator(if different from <br /> representative signing agreement) <br /> Email Address for ePermit Account: 1,� <br /> 1 Qy-auel . !c r--,m <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> COUNTY OF: ) ss. <br /> The foregoing instrument was acknowledged r/ <br /> before me this "/ - day of _ ct�, �. 7 by <br /> (date) !! (month) (year) <br /> ('Olt 5 e.n r •{--e i2_ as C. 0 a 7 r-c1 1-C r <br /> (Name of permittee representative) (title) <br /> of <br /> (permittee) <br /> ROBBIN SHACKELTON <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID x NOTARY PUBLIC MY COMMISSION EXPIRES AUGUST <br /> AUGUSTUST 78,2019 <br /> (seal) <br /> My Commission expires: C, <br /> Page 3 of 6 <br />