Laserfiche WebLink
Op(rrator(If Other than Permittee): 134j3) 60 a CRI t°P� �e�c�M�Adl 00 <br /> Per mittee Representative: ��A �� -S- <br /> Ceni feed Mail# :10 tf 2-2-90 evo0 .2 9 7 <br /> In aiccordance 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 informafion if required. <br /> Name Address Phone Number <br /> Clint Cross 201 Lake Drive Florissant, Colorado 80816 802-782-7330 <br /> W allace Bu rtis 66 Dartmouth Avenue, Colorado <br /> '5c4t,o <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 /> havl w been satisfied in accordance with these Rules and all applicable requirements under the AcL" <br /> Signature of P ittiee,Operator or their authorized agent Date <br /> Lmportant In accordance with Rules 4.14.2(a1 and 4.17.102 This release Muest must be submitted to the <br /> Div,ision via certified mail and separate from anyother correspondence to the Division. <br /> MmeralsReleaseR."WForm 20Sep2017 <br /> Page 2 of 2 <br />