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Operator(If Other than Permittee): <br /> Permittee Representative: Andrew Blackford <br /> Certified Mail# 40D 77 1"D npnq 52-63 538 <br /> In accordance with Rule 4.17.1(2)the Operator shall inclu a 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 /> Clay Carlson 12460 First St., Denver, CO 80241 303-324-2863 <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 /> 07-31 -2020 <br /> Signature ot Permittee, Opera r or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and separate om any other correspondence to the Division. <br /> Mmer&RelemeRequestporm 20Sep2017 <br /> Page 2 of 2 <br />