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Operator(If Other than Permittee): <br /> Permittee Representative: Keith NienhueSer <br /> Certified Mail# 9590-9402-4948-9063-6968 75 <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 /> Jeff Schumacher 1875 Rd. 37.5 Sterling Co. 970-520-5683 <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 /> 12/28/2020 <br /> ignature of Permi ee, 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 cent f ed mail and separate om any other correspondence to the Division. <br /> MinerelsRele Requmfform 20Sep2017 <br /> Page 2 of 2 <br />