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© ' COLORADO <br /> Division of Reclamation, <br /> Mining and Safety <br /> Department of Natural Resources <br /> CONSENT FOR ACCESS TO PROPERTY <br /> Name of Property Owner: �k0.V L Cd��e-t+ <br /> Location of Property: (�-t-{ i �{�2,�.wz.v �3 . M«k ('yy i <br /> / <br /> The Colorado Division of Reclamation Mining 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 access to your 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. ffowever, 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 /> XI am legally authorized to grant pennission to access the property described above. (PLC A-tr- L-�- <br /> 1 have read and I understand the information provided to nre regarding DRMS's request for consent to access <br /> my property. The information was provided to me in a language that I understand I have had the opimarrnio, <br /> to ask DRMS Staff questions. <br /> By signing below, I AGREE 1H allow DRMS Staff access to my property, and voluntarily provide my informed <br /> consent. <br /> Signature: . <br /> Nome of Landowner or Authorized Legal Representative(Printed): <br /> Date: IL2oZL <br /> of cow <br /> 1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 https://drms.colorado.;ov/ <br /> Jared Polis,Governor I Dan Gibbs,Executive Director I Virginia Brannon, Director <br /> -�*`76�` <br />