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Operator(If Other than Permittee): <br /> Permittee Representative: Carrie Hartwell <br /> Certified Mail# <br /> M-2018-050 <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 /> Highline Electric 1300 S Interocean, Holyoke CO 80734 (970) 854-2236 <br /> Jay Goddard 20247 CR 28, Julesburg CO 80737 (970) 580-8477 <br /> Neal Riecks 20605 CR 28, Julesburg CO 80737 (970) 466-0309 <br /> Diana Mendoza 20727 CR 28, Julesburg CO 80737 (970) 218-1800 <br /> Kenneth Bieber 20763 CR 28, Julesburg CO 80737 (970) 474-2323 <br /> Colo Welcome Center 20934 CR 28, Julesburg CO 80737 (970) 474-2054 <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 /> Important: In accordance with Rules 4 14 2(a) and 4.17.1 U This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MmeralsReleaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />