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of Cow QQ <br />COLORADO DIVISION OF RECLAMATION, MINING AND SAFETY <br />*, <br />6 1313 Sherman Street, Room 215, Denver, Colorado 80203 ph(303) 866-3567 <br />�s�s <br />REQUEST FOR FULL OR PARTIAL RELEASE OF PERMIT AREA <br />Please indicate if you are requesting: ❑ <br />FULL/FINAL RELEASE OF ENTIRE PERMITTED AREA <br />ACREAGE REDUCTION (PARTIAL RELEASE) <br />If you are requesting an acreage reduction, you will need to specify how many acres you wish to remove <br />from the existing permit under this revision. I 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 - <br />County: <br />Permittee: <br />Operator (If Other than Permittee): <br />Permittee Representative: <br />Certified Mail# <br />Site Name: <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 accordance with these Rules and all applicable requirements under the Act." <br />Signature of Permittee, Operator or their authorized agent Date <br />Important. In accordance with Rule 4.17.10This release request must be submitted to the Division <br />via certired mail and separate from any other correspondence to the Division. <br />