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Operator(If Other than Permittee): same <br /> Permittee Representative: Julie Mikulas 970-407-3631 <br /> Certified Mail # 7019 1640 0000 2371 6687 <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 /> Tim &Jeanne Iverson 5011 West F Street, Greeley, CO 80631 970-302-9051 <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 /> (Dk <br /> Sj46ature 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 re nest must be submitted to the <br /> Division via certified mail and separate om any other corres ondence to the Division. <br /> MineralsReleaseRequeslFarm Mep2017 <br /> Page 2 of 2 <br />