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OIL) <br /> _% COLORADO <br /> d Division of Reclamation, <br /> Mining and Safety <br /> Department of Natural Resources <br /> CONSENT FOR ACCESS TO PROPERTY <br /> Name of Property Owner: ory / r r LI(d(sC,n <br /> Location of Property: //y( cSP�;nc #Apd,Je� Wa.. rea4L.,.r L.q.� &0 5-V <br /> The Colorado Division of Reclamatio , Mi ing and Safety("DRMS") is requesting your consent to allow DRMS <br /> Staff to access your property on (date)and for any follow-up visits that DRMS determines <br /> to be necessary. DRMS seeks acces to y ur property to determine compliance with Colorado law and/or for the <br /> following purposes: <br /> Once granted access to your property,DRMS Staff may take actions including but not limited to: <br /> • Conducting a visual inspection of your property <br /> • Taking photographs,video, and/or other documentation of conditions on your property <br /> • Taking samples of soil, surface water, groundwater, or any materials stored on or disposed of on the <br /> property as DRMS determines to be necessary <br /> • Other actions related to determining whether conditions at the property violate Colorado law,raise <br /> concerns of potential impacts to health, safety,welfare or the environment, or require any emergency <br /> response action <br /> If DRMS Staff identifies any potential violations of laws or regulations at your property,you could face legal <br /> action, including but not limited to fines and/or requirements that you obtain any necessary permits. <br /> You are not required to consent to this request for access to your property. However, if you do not consent, <br /> DRMS Staff may still obtain access to your property through an administrative search warrant or other legal <br /> means. DRMS may also conduct an aerial inspection(e.g.,drone flight)of your property without obtaining your <br /> consent. So, if you do not consent, it is still possible that DRMS Staff will be able to inspect your property. <br /> Informed Consent <br /> Check one: <br /> I own the property identified above. <br /> I am legally authorized to grant permission to access the property described above. <br /> I have read and I understand the information provided to me regarding DRMS's request for consent to access <br /> my property. The information was provided tome in a language that I understand. I have had the opportunity <br /> to ask DRMS Staff questions. <br /> By signing below,IAGREE to allow DRMS Staff access to my property,and voluntarily provide ml,informed <br /> consent. <br /> Signatur e: ,4& <br /> Name of Landowner or Authorized Legal Representative (Printed): <br /> Date: <br /> c <br /> 1313 Sherman Street, Room 215,Denver,CO 80203 P 303.866.3567 F 303.832.8106 https://drms.coLorado.gov/ e4 <br /> of oto <br /> Jared Polis,Governor I Dan Gibbs, Executive Director I Virginia Brannon, Director ( y `. <br /> �+ s <br /> 1976�� <br />