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Operator(If Other than Permittee): <br /> Permittee Representative: Tom Brubaker <br /> Certified Mail# �0 V 9 ? 0 60 O( I q 33 A 9 <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 /> VALCO INC DBA CERTIFIED CON CO A COLOC CORP 9121 SUNSHINEMEADOW PL, PARKER, CO80134 303-862-7569 <br /> VALCO INC AKA LAMAR VALLEY CONCRETE CO A COLORADO CORP 9121 SUNSHINE MEADOW PL,PARKER,CO 80134 303-862-7569 <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 /> 41., ap 10/29/2021 <br /> Signature of Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2L) 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 /> MmeralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />