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Operator (If Other than Permittee): <br />Permittee Representative: Christine Felz, Land and Environment Manager <br />Certified Mail # 701 6075000007384233 <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 />Todd Williams 8876 Rogers Rd Longmont, CO 80503 303-653-3940 <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 />J <br />Signature of Permittee, Operator or their authorized agent <br />Ol-- O l �� <br />Date <br />Important: In accordance with Rules 4.14.2 a and 4.17.1 (3) This release re nest must be submitted to the <br />Division via certified mail and separate from any other coriMondence_to the Division. <br />Minenlskeleaz RequenFmm 2CSM'017 <br />Page 2 of 2 <br />