2005-01-12_REVISION - M1999120 ‎(2)‎

• Permit No: M1999120
• IBM Index Class Name: Revision
• Doc Date: 1/12/2005
• Doc Name: Rescheduled Pre-Hearing Conf. and Formal Public Hearing
• From: DMG
• To: Parties and Interested Persons
• Type & Sequence: AM1
• Media Type: D
• Archive: No

AUTIIORIZATION TO P.EPRESENT A PARTY
(Please Type Or Print The Requested Information)
SIGNATURES MUST BE IN BLUE INK
I
(person's name)
of
authorized to delegate
(person's name) (consultant, etc.)
to represent (name of person, company, association, organization,
etc.) at the Pre-hearing Conference and/or Hearing before the Mined Land Reclamation B oard in
this matter. ~ .
SIGNED AND DATED T13IS DAY OF ,
If corporation attest (seal)'
Authorized Signature (must be signed in blue ink)
Title: - - - - - - - -
State of )
ss
County of )
The foregoing instrument was aclmowledged before me this
by as
of
Notary Public
My commission expires:
SIGNATURES MUST BE IN BLUE INK
(title)
(name of company, association, organization, etc.) am
,a
day of

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