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A. <br />r <br />Operator (If Other than Pennittee): <br />Pennittee Representative: Dave Hornung <br />Certified Mail # i / U 3 Y o 000 / 0-,Toy <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 />Mike Bohnen 23851 Co Rd 40 <br />Bethune Colorado 80805 <br />719-349-5895 <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: l / — .2-,2/ <br />Signature of Permittee, Operator or their authorized agent Date <br />ImVortant: 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 fi-om any other correspondence to the Division. <br />M ineial.Rele—ReyuestFom 20Sep2017 <br />Page 2 of 2 <br />