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<br />AUTHORIZATION TO REPRESENT ~ PARTY <br />(Please Tvpe Or Print The Requested Information) <br />SIGNATURES MUST BE L~ BLCE iNR <br />I G~ ~i r~~ <br />(Person's Name) <br />(Title) <br />of (nameTof company, association, organization, etc.j am <br />authorized to delegate ~A'~~~L!' ~~t° ~ , a ~ V <br />Person's Name) ( nsuftant, etc.) <br />to represent ~ ~ fi'/ /G _ (name of person, company, association, <br />organization, etc.) at the Pre-hearing Conference and/or Hearing before the Mined Land Reclamation <br />9'~',jS"3 '"d~~3 <br />Borad in this matter. Representative's phone number ( ~- ,and address <br />(Street Address) (City) (State) (ZIP) <br />SIGNED A DATED THIS ,~DZ DAY OF l , -E;~--. <br />i <br />If corporation attest (seal) <br />Authon tgne ure (musr be signed in blue ink) <br />STATE OF (//lK1V <br />/~ ) ss. <br />COUNTY OF G ~ ) ~~ <br />The foregoing instrument was acknowledged before me thiso~day of I I~t^^rl, (-.X 0 `-' I <br />by as o <br />~. , _ '~. <br />e <br />:' ' <br />_~ J "_.^ <br />F y '~ <br />0 ARY PUBLIC = ~ ' % ~ - ' " <br />- ~ _~ = <br />i r_ <br />My Commission expires: _ __ ___ <br />~'~um~lPa"~ipliavOer~~ei4 ?OpR <br />,,,.~ <br />SIGNATURES iv1UST BE IN BLUE iNK ~ " ~-~ <br />RECEIVED <br />MAY 2 3 201 <br />Division of Minerals and Geology <br />•~I:bsssy~nU mlwnaauan m R<p¢um a Pant tlac <br />