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Operator(If Other than Permittee): <br /> Permittee Representative: Jodi Schreiber <br /> Certified Mail# <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 /> Dwight & Julie Proctor 24625 CR 23, LaJunta, CO 81050 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 /> 2/9/2021 <br /> Sigua ttee, r or tFeir au-nwrffed agent late <br /> Important. In accordance with Rules 4.14.2(a)and 4.17.1 L) This release Merest must be submitted to the <br /> Division via certified mail and separate from go other correspondence to the Division. <br /> MioasbRakreRegoepFotm 217 <br /> Page 2 of 2 <br />