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Operator (If Other than Permittee): <br /> Permittee Representative: Mark Johnson <br /> Certified Mail # i o <br /> ODUO ���Z1 Ns �1S <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 /> Town of Milliken 1101 Broad St. Milliken, CO 80543 9705874331 <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 // 11 /21 /2019 <br /> Signature o er ' , perator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.1(3) This release request must be submitted to the <br /> Division via certified mail and separate rom any other correspondence to the Division. <br /> MineralsReleaseRequestForm 20Sel)201 7 <br /> Pape 2 of 2 <br />