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1/29/25Y 5:51 PM ePermitting Administrator Change Form <br /> Name(s) and Permit Number(s) of any additional person(s) to notify on annual report/map/fee <br /> due date(s): <br /> jason.burkey@na.crh.com M2022030 M2003037 M1977023 M1977098 M1977132 M1977205 M1978287 <br /> M 1978349 M 1979205 M 1980136 M 1981014 MI 983142 M 1986002 M 1988037 M 1991136 M 1994005 <br /> M1994097 M1995036 M1998014 M2000113 M2001100 M2001113 M2005021 M2005075 M2006018 <br /> M2010058 M2012050 M2002114 M1996082 M1990021 M1980022 <br /> .......................................................................................................................................................................................................................................................................................................................................................... <br /> Email address(es) of additional person(s) to notify on annual report/map/fee due date(s): <br /> jesse.farmer@unitedco.com M2022030 M2003037 M1977023 M1977098 M1977132 M1977205 M1978287 <br /> M 1978349 M 1979205 M 1980136 M 1981014 M 1983142 M 1986002 M 1988037 M 1991136 M 1994005 <br /> M1994097 M1995036 M1998014 M2000113 M2001100 M2001113 M2005021 M2005075 M2006018 <br /> M2010058 M2012050 M2002114 M1996082 M1990021 M1980022 <br /> .......................................................................................................................................................................................................................................................................................................................................................... <br /> By clicking "Agree" below, you opt in to ePermitting for report submittal, and consent that the <br /> Division may send any and all correspondence, notices, documents and information to you <br /> electronically, in all matters related to reports and fees for your Permit(s) and/or N01(s). You <br /> further consent that you will use ePermit to send any and all correspondence, notices, <br /> documents and information to the Division in all matters related to reports and fees for your <br /> Permit(s) and/or N01(s). You consent that documents submitted electronically to the Division <br /> have the same legal force and effect as paper documents. The Division reserves the right to <br /> send any or all electronic records to you in paper form to your current mailing address on file at <br /> its sole discretion. Your agreement to opt in to ePermit represents a single legal transaction as <br /> that term is used in C.R.S. § 24-71.3-105. Your agreement to opt into ePermit will become <br /> effective immediately upon the Division's receipt of this signed Agreement and you may no <br /> longer receive paper documents from the Division pertaining to reports and fees for your <br /> Permit(s) and/or N01(s). This Agreement, including the validity of any signatures or consents, <br /> any claims, or any disputes arising hereunder shall be construed in accordance with and <br /> governed by the Laws of the State of Colorado. Further, if the permit or N01 holder is a <br /> corporation, partnership, trust, etc., you state that you are authorized to act on behalf of the <br /> permittee or N01 holder. <br /> 0 Agree <br /> This form was created inside of State.co.us Executive Branch. <br /> https://docs.google.com/forms/d/1 QY6C6w2BMyQoAmu1_DFtS5wVHlfoeUraQePxvehJJac/edit#response=ACYDBNgOQpJcVreaKh3uCtyk015OLvp5... 3/4 <br />