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Operator(If Other than Permittee): <br /> Permittee Representative: Kevin Anderson 970 214-1601 kanderson@connellresources.com <br /> Certified Mail# --1 p\1 05 30 000\ D 1$b \ZZO <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 /> Serfer Land Ventures 3064 S CR 5 Chris Serbousek <br /> Ft. Collins, CO 80525 303 419-6781 <br /> Cory Urban <br /> 970 689-2045 <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 /> Kevin D. Anderson Digitally signed 9D�erson 6-3-2020 <br /> Date:2020.06.03 11:08:36-06'00' <br /> Signature of Permittee, Operator 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 from any other correspondence to the Division. <br /> Min—IsRelea eRequesff—20Sep2017 <br /> Page 2 of 2 <br />