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( 1 4 <br /> Operator(If Other than Permittee): <br /> Permittee Representative: Darren Janssen (303) 526-8842 djanssen@crccllc.com <br /> Certified Mail# 7011 ZW 0000 7748 yyl,S <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 /> Anthony Vick 3501 Count Road 44.5, Hugo, CO 80821 (719) 740-3211 <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 /> —' yl�z <br /> Si a e of a ee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2[a) and 4.17.1 Q) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MineralsReleaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />