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Operator(If Other than Permittee): <br /> Permittee Representative: Brad Farlcher <br /> Certified Mail # 70192970000200658453 <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 /> Loveland Ready-Mix Concrete, Inc PO Box 299, Loveland CO 80539 970.667.2680 <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 /> e I X�,�,�e .i"_�; I ZL-1.0, 5�� - 6 ._,9_z�-zo 2l <br /> ignature of Permittee, Oper for or t eir 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 certified mail and separate from any other correspondence to the Division. <br /> MineralsReleaseRequesrForm 20Sep20I7 <br /> Page 2 of 2 <br />