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Colorado Calumet Co.,Inc.—Consent Agenda Form—M-2017-003 <br /> September 26,2019 <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 v< 6, day of •ea e n b vt- , a l <br /> (Day) (Month) (Year) <br /> Operator: aGc;iP✓I b o CA L V4107" <br /> Representative: /3/ ,I AV K . z e--g <br /> Title: s Evi <br /> Signature: <br /> State of C olo r, o ) <br /> ss. <br /> County of 3e-Ff er S on ) <br /> The foregoing instrument was acknowledged before me this a� day of Sep fe„,t e&, <br /> II 1 (Day) (Month) (Year) <br /> by Bryan K- LeeS �p as I rfS;d en 1 of Color Ago (f IIV »ef Co•t Znc.. <br /> (Representative) (Title) (Operator) <br /> EILEEN S HANSEN Notary Public <br /> NOTARY PUBLIC <br /> STATE OF COLORAW My Commission Expires: <br /> My�pgNOTARY j IAA�Y411�,20Q'1 <br /> SIGNATURES MUST BE IN BLUE INK <br />