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Operator(If Other than Permittee) <br /> Permittee Representative: Chris Zadel <br /> Certified Mail # 74>1 d �,j -"dc' 5-2°/t /xV i71 - <br /> ----- ---------_-..-.-_._---------------------- ----- ---- --- <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 /> Pioneer Land Company, LLC 4409 Coriolis Way, Frederick, CO 80504 (303) 550-5957 <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 /> Signature of Permittee, Operator or their authorized agent Date <br /> lr>r�,�»ttlnt hr i,nh R1rle i; 4.14.2tcrl_ynd 4.1-�. 1(3)_l his ITlecrce rrL( st must be submitted to--the <br /> Division via certified mail and separatelrom ani,,other correspondence to the Division. <br /> Mme kReleaeReq—ttomi'_USep2U 17 <br /> Page 2 of 2 <br />