2017-12-19_GENERAL DOCUMENTS - M2004053

• Permit No: M2004053
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 12/19/2017
• Doc Name: Agreement to Conduct Permitting by Electronic Means
• From: Rivera's Excavation Gravel Pit
• To: DRMS
• Email Name: SLB
• Media Type: D
• Archive: No

Agre0ment to Conduct Permitting by Electronic Means
Name of permittee representative desiring to
opt in to ePermit: Fl'yert s J�'V eowa )on 6y'cc0,eL
Title:
Sole --owe er,
Name of permittee:Signature:
ePermitting Administrator(if different from ©c� icf— irso e\
representative signing agreement) b�R /� ►,l tJ� -
Email Address for ePermit Account: �+
Notarized Affidavit of Si nag ture
STATE OF: /� ��/ )
lV P c,y / � l e.x f Gd
COUNTY OF: T ) ss.
l 0.lN
The foregoing instrument was acknowledged CrD
before me this 13 day of DeXCM 20 17 by
(date) (month) (year)
as
(Name of permittee representative) (title)
of
(permittee)
NOTARY PUBLIC
(seal)
My Commission expires:
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