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Operator (If Other than Permittee): <br />Permittee Representative: Clint Beck <br />Certified Mail # 7016 0910 0000 5705 5273 <br />In accordance with Rule 4.17.1(2) the Operator shall include the names, addresses and phone numbers of all <br />owners of record to the affected land. Please attach additional sheets for this information if required. <br />Name Address Phone Number <br />BLM 2300 River Frontage Rd., Silt, CO 81652 (970) 876.9018 <br />In accordance with Rule 4.17.1(4), if requesting a partial acreage release the Operator or their agent MUST sign that <br />they have complied with the following statement: "All applicable portions of the Reclamation Pian requirements <br />have been satisfied in accordance with these Rules and all applicable requirements under the Act." <br /># , 0 a�&- tt <br />Signature-oSignatuni-oT Permittee, Operator or their authorized agent Dat <br />Important: In accordance with Rides 4.14.2(a) and 4.17.1 3 This release request must be submitted to the <br />Dlvisiol7 via cen'ti led mail and se arale -om any other coi•res ondence to the Division - <br />M a=IsReleweRequeaForm Mep=T <br />Page 2 of 2 <br />