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folly Pit <br /> M-2012-010 <br /> Page 3 of 3 <br /> December 9,2024 <br /> Operator's Notarized Signature: <br /> As an authorized representative of the Applicant, I hereby attest that the Operator concedes to the above <br /> described violation and agrees to comply with the Corrective Action and Civil Penalty proposed in this <br /> STAFF SUMMARY FORM FOR CONSENT AGENDA ITEMS. <br /> Signed and dated this Z— day of D�LG+- 6, ' ,20-?4- - <br /> LAA5At✓r-,q-4=n- <br /> (Operator) <br /> Signature: <br /> f <br /> Title: SV�I��✓!S&r <br /> State of b <br /> County of L-i 41 '`'t A—!-> <br /> The foregoing instrument was acknowledged before me this 10' day of 0 20� <br /> by a 9© 1� as !s9 of l q.5 �-n MQ'S Cp U41- Pit)ad G�, d <br /> _ � r 1k, <br /> SUSAN K GUTIERREZ <br /> Notary Public <br /> Notary Public <br /> State of Colorado .� <br /> Notary ID#19984025752 My Commission Expires: <br /> M Commission Ex fires 09 16-2026 <br /> SIGNATURES MUST BE IN BLUE INK <br />