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i <br /> Operator(If Other than Permittee): <br /> Permittee Representative: s o-r, swen'-saagC�0 <br /> Certified Mail # <br /> In accordance with Rule 4.17.1(2)the Operator shall include the names,addresse and phone numbers of all <br /> owners of record to the affected land. Please attach additional sheets for this in ation if required. <br /> Name Address Phone Number <br /> Chad 7"h��s U 1, q 303-300-7100 <br /> co, Tos4o <br /> L.a.✓Y V_Ty1P..��S g� � �nG�' e.✓' <br /> In accordance with Rule 4.17.1(4), if requesting a partial acreage release the Opera or or their agent MUST sign that <br /> they have complied with the following statement: "All applicable portions of the eclamation Plan requirements <br /> have been satisfied in accordance with these Rules and all applicable requirements rider the Act." <br /> Signatur of Permittee, Operator or their authorized agent ate <br /> Important: In accordance with Rules 4.14.2 a and 4.17.1 3 This release reauest must be submitted to the <br /> Division via certified mail and separate from any other corresl2ondence tote Division. <br /> MinemisReleweRequestForm 20Sep2017 <br /> Page 2 of 2 <br /> I <br />