2022-02-07_PERMIT FILE - M2021068

• Permit No: M2021068
• IBM Index Class Name: Permit File
• Doc Date: 2/7/2022
• Doc Name: Consent Agenda Summary Form
• From: Joe Forster
• To: DRMS
• Email Name: MAC
• Email Name: GRM
• Email Name: AME
• Media Type: D
• Archive: No

Jack D.Tabb,LLC
Page 3 of 3
February 1,2022
Operator's Notarized Signature: As an authorized representative of the Operator, I hereby
attest that the Operator concedes to the above described violation and agrees to comply with the
Cease and Desist Order, Corrective Action, and Civil Penalty proposed in this STAFF
SUMMARY FORM FOR CONSENT AGENDA ITEMS.
Signed and dated this day of �� ✓ a�G '�
(Opera or
Signature:
Title: CC)0
State of
ss.
County of
The foregoing instrument was acknowledged before me this day of
by t)5 f as of TA
CINDY PECHA Notary Public
SNOTARY PUBUC l �J
STATE OF WISCONSIN My Commission Expires: r _ 0� 7
SIGNATURES MUST BE IN BLUE INK