PERMFILE45663

• Permit No: M2002004
• IBM Index Class Name: Permit File
• Doc Date: 4/29/2002
• Doc Name: Citizen participation Memo
• From: DMG
• To: Debra Eiland
• Media Type: D
• Archive: No

AUTHORIZATION TO REPRESENT A PARTY
(Please Tyne Or Print The Requested Information)
SIGNATURES MUST BE IN BLUE INK
I
(person's name)
of
(title)
(name of company, association, organization, etc.) am
- _ _.
authorized Yo delegate- , a
(person's name)
(consultant, etc.)
to represent (name of person, company, association, organization,
etc.) at the Pre-heazing Conference and/or Hearing before the Mined Land Reclamation Boazd in
this matter.
SIGNED AND DATED THIS DAY OF
If corporation attest (seal)
Authorized Signature (must be signed in blue ink)
Title:
State of )
ss
County of )
The foregoing instrument was acknowledged before me this
by
day of
as
of

Notary Public
My commission expires:
SIGNATURES MUST BE IN BLUE INK
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