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y s <br /> M-1997-015 <br /> Consent Agenda Form <br /> July 29, 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 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 /> Signed and dated this rd day of 'lU U , 2016. <br /> Operator: Washington County <br /> Name: �� 0 (please print clearly): <br /> Signature: <br /> Title: <br /> State of 010 F60 b ) <br /> ss. <br /> County of Loa 1 ) <br /> The foregoing instrument was acknowledged before me this rd day of AU it 5 t2016, <br /> by D 1)%( Fes, as &021N f65)pp of Washington County. <br /> DEBRA S.COWAN ' <br /> NOTARY PUBLIC Not4y Public <br /> STATE OF COLORADO <br /> NOTARY ID 20014039846 My Commission Expires: 17 <br /> MY COMMISSION EXPIRES DECEMBER 21,2017 <br /> SIGNATURES MUST BE IN BLUE INK <br />