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Operator (If Other than Permittee): <br /> Permittee Representative: Calvin Feik <br /> Certified Mail 4 7012164000066878493 <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 /> Bent County PO Box 350, Las Animas, CO 81054 719-456-2223 <br /> Robert & Ronda Bucholz 8611 County Rd GG, Las Animas, CO 81054 719-221 -0637 <br /> Dale B Kortz PO Box 215,2241 Bear Creek Rd, Bayfield,CO 81122 970-884-9100 <br /> Laura & David Miller 21755 County Rd 3.5, Las Animas, CO 81054 719-456-1872 <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 /> a 2� <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 /> MineralsReleaseRequeslForm 20Sep2017 <br /> Page 2 of 2 <br />