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Operator (If Other than Permittee): <br /> Permittee Representative: Jodi Schreiber <br /> Certified Mail # 7020 1810 0000 1557 2829 <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 /> Triview Metropolitan District 16055 Old Forest Point, Suite 300 719-488-6868 <br /> PO Box 849 <br /> Monument, CO 80132 <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 /> 10/21 /2021 <br /> SP* WrWe-o-f ermittee, 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 /> Min=IsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />