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M-2000-018 <br /> Consent Agenda Fonn <br /> August 12, 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 lZ_�" day of 92016. <br /> Operator: Cheyenne County <br /> Name: —PvJ Pe li on (please print clearly): <br /> Signature: ;eln: <br /> Title: C hai r man <br /> State of <br /> ss. <br /> County of k\ ) Q' <br /> The foregoing instrument was acknowledged before me this 0 day of 4J , 2016, <br /> b F, ^ as of Che erne Count . <br /> y � � �. �� �. d��" anae� y v <br /> n <br /> C <br /> NOTEUGHERTY <br /> pUM Notary Public <br /> STATE OF COLORADO <br /> NOTARY ID 201W7448 My Commission Expires: �= ' <br /> W COWASSION EXPIRES FEBRUARY 20,2019 <br /> SIGNATURES MUST BE IN BLUE INK <br />