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Operator(If Other than Permittee): Ka Cy F l e m 0 n S <br /> Permittee Representative: ,Jed SonnenSheln <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 /> Rick Mitchell and Elizabeth Mitchell P.O. Box 10, Bennett, CO 80102 (303)870-4260,(303)339-0602 <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 /> Ka cy F I e m O n S Digitally signed by Kacy Flem ' 07/12/2 021 <br /> Date: 2021.07.12 09:269:26:51 -0600' <br /> Signature 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 request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MineralsRelea Requesfform 20Sep2017 <br /> Page 2 of 2 <br />