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Operator (If Other than Permittee): Weld County Public Works <br /> Permittee Representative: Clay Kimmi <br /> Certified Mail # 70160340000001131319 <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 /> Weld County PO Box 758, Greeley, CO 80632 970-400-3741 <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 Plan requirements <br /> have been satisfied in accordance with these Rules and all applicable requirements under the Act." <br /> C I pi ILVI <br /> h f 12/13117 <br /> Signatuiq of Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.1 Q) This release request must be submitted to the <br /> Division via cert{fled mail and separate fi-om any other correspondence to the Division. <br /> MmeralsReleawRequestForm 20Sep2017 <br /> Page 2 of 2 <br />