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M-2004-052 <br />Consent Agenda Form <br />April 1, 2016 <br />Page 3 of 3 <br /> <br />Operator’s Notarized Signature: As an authorized representative of the Operator, I hereby attest that <br />the Operator concedes to the above described violation and agrees to comply with the Cease and Desist <br />Order, Corrective Action, and Civil Penalty proposed in this STAFF SUMMARY FORM FOR <br />CONSENT AGENDA ITEMS. <br /> <br /> <br />Signed and dated this ________ day of April, 2016. <br /> <br />Phillips County <br />(Operator) <br /> <br />Signature: _____________________________________________ <br /> <br />Title: __________________________________________________ <br /> <br /> <br />State of _____________________________ ) <br /> ) ss. <br />County of ___________________________ ) <br /> <br />The foregoing instrument was acknowledged before me this ______ day of April, 2016, <br /> <br />by ________________________ as _____________________________ of Phillips County. <br /> <br /> <br /> _________________________________________ <br /> Notary Public <br /> <br /> My Commission Expires: ____________________ <br /> <br /> <br /> <br />SIGNATURES MUST BE IN BLUE INK <br /> <br />