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A <br /> Operator(If Other than Permittee): NSA <br /> Permittee Representative: Steve Lindner <br /> Certified Mail# 701 -7 019 Q 00 O 0 4 b 11k 3`7 8 '2- <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 /> South Forty Recreation,LLC(Steve Lindner,Manager) 759 Apache Drive, Canon City, CO 812120 (719) 371-3104 <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 /> /7 <br /> Signature of Permittee, perator or their authorized agent D e <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 certified mail and separate from any other correspondence to the Division. <br /> MincmisReleweRequestForm 20Sep2017 <br /> Page 2 of 2 <br />