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Agreement to Conduct Permitting by Electronic Means <br /> DEC 01 Lull <br /> DlYISl(M OF RECLAMATION LU i l <br /> Name of permittee representative desiring to <br /> .G ANQ S FTy V� <br /> opt in to ePermit: <br /> Title: j�&m-e/" <br /> Name of permittee: �7 1j.. CUSS;CnS AM , <br /> qJf?C <br /> Signature: <br /> ePermitting Administrator(if different from <br /> representative signing agreement) CIS �17e <br /> Email Address for ePermit Account: <br /> Notarized Affidavit of Si mature <br /> ature <br /> STATE OF: ) <br /> COUNTY OF: ) ss. <br /> The foregoing ins nt was acknowledged <br /> before me this day of �) ru AC)t-7 by <br /> n / (date) (month) (year) <br /> as <br /> e <br /> (Name of permittee representative) (title) <br /> of <br /> (permittee) <br /> NOTARY P L <br /> ENc;twy <br /> ANA tuMTOKL <br /> (seal) ILIC.STATE OF COlORJ1o0ntlf cation#20154025700 <br /> My Commission expires: ission E.ves 613012019 <br /> L2 [30 �QLI� <br /> Page 3 of 6 <br />