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• Operator(If Other than Permittee): Same <br /> Permittee Representative: Connie N. Davis <br /> Certified Mail # 7016 0750 0000 7384 2765 <br /> In accordance with Rule 4.17.1(2)the Operator shall idclude 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 /> CITY OF THORNTON 9500 Civic Center Dr., Denver, CO 80229 303-538-7200 <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 /> Signature of Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> Mine IsRele seRequefform 20Sep2017 <br /> Page 2 of 2 <br />