PERMFILE123402

• Permit No: m2004044
• IBM Index Class Name: Permit File
• Doc Date: 11/24/2004
• Doc Name: Application Revised Change Consideration Date
• From: DMG
• To: Tetra Tech RMC
• Media Type: D
• Archive: No

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

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