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N/1-4 980-2=4=4 <br /> Consent Agenda Form <br /> May 24, 2016 <br /> Page 3 of 3 <br /> Operator's Notarized Signature: As an authorized representative of the Operator, I hereby attest that <br /> the Operator voluntarily consents to the above described violations and agrees to comply with the Cease <br /> and Desist Order, Corrective Action, and Civil Penalty proposed in this STAFF SUMMARY FORM <br /> FOR CONSENT AGENDA ITEMS. <br /> Signed and dated,tbis day of y , 2016. <br /> I <br /> Operator: Cri 1 C eek &Vi for Gold Mining,Company <br /> Name: h (please print dearly): <br /> Signature:` <br /> Title: <br /> State of <br /> County of ` ' } ss.) <br /> The foregoing instrument was acknowledged before me this day o ���', 2016, <br /> by\JELL-k (\ 1<--:, as C A\ t 1 of Cripple Creek & Victor <br /> Gold Mining Company. <br /> MI►RIE Y t <br /> ?.s'�•••• " , Notary Public <br /> a! NoTARy <br /> My Commission Expires: <br /> PUBLIC <br /> ......... <br /> SIGNATURES MUST BE IN BLUE INK <br />