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Consent Agenda Form <br /> M-1980-244 <br /> March 1,2024 <br /> Page 3 of 3 <br /> Operator's Notarized Signature: As an authorized representative of the Operator, I hereby <br /> attest that the Operator voluntarily consents to the above-described violation and agrees to <br /> comply with the Cease and Desist Order, Corrective Action, and Civil Penalty proposed in this <br /> STAFF SUMMARY FORM FOR CONSENT AGENDA ITEMS. <br /> Signed and dated this day of_ ArC_L , 2024. <br /> Operator: Cripple Creek& Victor Gold Mining Company <br /> Name: ,Loci 1-The, \QS <br /> Signature: <br /> Title: C>✓n of ON-ot_ft;4.5 ex- <br /> State of C t0fcc-Ct d ) <br /> ) ss. <br /> County of T . ( ke-r ) <br /> The foregoing instrument was acknowledged before me this day of )(RA_rC-1"-", 2024, <br /> by I l as cv e , <br /> (name) (title) <br /> of Cripple Creek& Victor Gold Mining Company. <br /> NormaTownley ��7NOTARYYPUBLICSTATE OF COLORADO l/'✓z��5e1C, <br /> NOTARY ID 19934016402 Notary Public <br /> MY COMMISSION EXPIRES DECEMBER 21,2025 <br /> My Commission Expires: / <br /> PLEASE PRINT PRINT CLEARLY <br /> SIGNATURES MUST BE IN BLUE INK <br />