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Operator(If Other than Permittee): <br /> Permittee Representative: Gerald Daub, Daub & Associates, Inc. <br /> Certified Mail # .--- x/� # 77 L� liS�`9' �q`f <br /> c' — -70. ;� <br /> In accordance with Rule 4.17.1(2)the Operator shall include the names, addresses and phone Zbers 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 /> BLM White River Field Office 220 E. Market Street Meeker, CO 81641 (303) 239-3923 <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 /> r� /D b' �i <br /> ignature, f PeAiifiee, 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 /> MineralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />