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Operator(If Other than Permittee): same <br /> Permittee Representative: Michael Ripp, P.O.Box 54, Delta, CO 81416 (970) 874-5127 <br /> Certified Mail # D/ 9 v2 (pi) c'o / 6 7,5- 174.5-4 <br /> 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 /> Bill St. James P.O. Box 999 Winter Park, FL 32790 (407) 399-5799 <br /> Joe and Frances Loughrey 1658 H5 Lane, Delta, CO 81416 (970) 874-9507 <br /> Glen Black 691 1675 Road, Delta, CO 81416 (970) 260-1696 <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 /> 74,144: 40 '71-_3 _ <br /> Si ature of Permittee, O. ator ., 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 from any other correspondence to the Division. <br /> MineralsReleaseRequestForm 20Sep2017 <br />