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Operator (If Other than Permittee): <br />Permittee Representative: Jodi Schreiber <br />Certified Mail # 70142120000167009495 <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 <br />Dwight & Julie Proctor <br />Address <br />Phone Number <br />24625 CR 23, LaJunta, C081050 719-384-8611 <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 />11/2/2020 <br />or their authorized agent Date <br />Important.- In accordance with Rules 4.14.2 a and 4.17.1 0) This release re uest must be submitted to the <br />Division via certified mail and separatefrom any other correspondence to the Division. <br />Mka*i&ft1emRegnes1Form 20Sep2017 <br />Page 2 of 2 <br />