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Motorcross Revised Consent Agreement <br /> Page 4 of 4 <br /> September 27,2021 <br /> Operator's Notarized Signature: <br /> As an authorized representative of the Applicant, I hereby attest that the Operator concedes to <br /> the above described violation and agrees to comply with the Corrective Action and Civil Penalty <br /> proposed in this STAFF SUMMARY FORM FOR CONSENT AGENDA ITEMS. <br /> Signed and dated this day of �c , 2021. <br /> 6i: . (.'j <br /> (Applicant) <br /> Signatur <br /> Title: fi2ufQ—r ��,ara t��2 <br /> State of e Ioy-r'j o <br /> County of 4.k0'P_ <br /> The foregoing instrument was acknowledged before me this day of �,e� , 2021, <br /> by 67a,14;l MAJ&e-,� as`1 ieCT- I- of <br /> JULIE WZ WZ ILSON <br /> NOTARY PUBW a ry Public <br /> STATE OF COLORADO <br /> NOTARY ID# 20194039967 <br /> MY COMMISSION p(?IRES October 18.2023 <br /> My Commission Expires: ( O 2D2--3 <br /> SIGNATURES MUST BE IN BLUE INK <br />