2017-11-14_REPORT - M1995017

• Permit No: M1995017
• IBM Index Class Name: Report
• Doc Date: 11/14/2017
• Doc Name: Annual Fee/Report/Map
• From: City of Sterling
• To: DRMS
• Annual Report Year: 2017
• Email Name: JLE
• 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 ePennitting Documents
on the Company's behalf is terminated.
Further, Affiant sayeth not.
Affiant's name
Signature
STATE OF:
Notarized Affidavit of Signature
}
COUNTY OF: ) ss.
The foregoing instrument was acknowledged
before me this day of by
(date) (month) (year)
as
(Name of permittee representative)
(seal)
My Commission expires:
of
(title)
(permittee)
Page 5 of 6
NOTARY PUBLIC