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Operator(If Other than Permittee): <br /> Pennittee Representative: Dave Hornung <br /> Certified Mail # 70/(, 0:3Z10 15oo/ 050y <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 /> Robert Bledsoe PO Box 435 <br /> Hugo, Colorado 80821 <br /> 719-962-3369 <br /> In accordance with Rule 4.17.1(4), if requesting a partial acreage release the Operator or their agent MUST <br /> sign that they have complied with the following statement: "All applicable portions of the Reclamation Plan <br /> requirements have been satisfied in accordance with these Rules and all applicable requirements under the <br /> Act." <br /> Date: <br /> Signature of Permittee, Operator or their authorized agent Date <br /> Itnj2ortant: In accordance with Rules 4.14.2(a,) and 4.17.1 L) This release request must be submitted to the <br /> Division via certified mail and se4zarate,from any other correspondence to the Division. <br /> \LnuaLRcica}eRequc.tForm 20S.p2017 <br /> Page 2 of 2 <br />