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COLORADO DIVISION OF RECLAMATION, <br />WiING AND SAFETY <br />1313 Sherman Street, Room 215, Denver, Colorado 80203 ph(303) 866-3567 <br />REQUEST FOR FULL OR PARTIAL RELEASE OF PERMIT AREA <br />Please indicate if you are requesting: <br />FULLIFI AL RELEASE OF ENTIRE PERMITTED AREA <br />ACREAGE REDUCTION (PARTIAL RELEASE) <br />If you are requesting an acreage reduction, you will need to specify h�ol many acres you wish to remove <br />from the existing permit under this revision. l wish to release_ acres at this time. <br />You will also need to submit updated mining and reclamation plan maps that accurately depict both the <br />proposed acreage to be released from the current permit area, and the resulting new permit boundary. <br />File No.: M- I Site Name: <br />Count}•:4&J <br />Permittee: <br />Operator (If Other than Permittee): <br />Permittee Representative: -0 <br />Certified Mail# <br />In accordance with Rule 4.17.1(2) the Operator shall include the names, addresses and phone numbers <br />of all owners of record to the affected land. Please attach additional sheets for this information if <br />required. <br />in accordance with Rule 4.17.1(4) the Operator or their agent MUST sign that they have complied with <br />the following statement: "All applicable portions of the Reclamation Plan requirements have been <br />satisfied in accordapce with these Rules and all applicable requirements under the Act" <br />Signature of Permittee, Operator or their authorized agent Date <br />via cern ted mail and se ate man other comes ondence to the Division. <br />ZZ'd 9909-Zti8-OL6 011 eBue4ox3100lseAII d6£:b0 9 L 9 L Int <br />