Laserfiche WebLink
Operator (If Other than Permittee): NSA <br /> Permittee Representative: MICHAEL VOLOSIN <br /> Certified Mail# <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 /> Pamela Ard 24098 COUNTY ROAD 50 LA SALLE CO 80645 720-323-1960 <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 4.17.1 L) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MmeralsRelcaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />