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Operator(If Other than Permittee): <br /> Permittee Representative: Tim McCracken - Delta County Engineer/Authorized Agent <br /> Certified Mail# - / 0 21 0 3 S d Q 6 D( 3 q f 3 2 G ,?' <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 /> Lemoine William P Jr Revocable Trust Dated 4-16-15 35476 Hanson Mesa Road Hotchkiss,CO 81419-6701 970.872.3948 <br /> Gruber, Danielle N P.O. Box 141 Hotchkiss, CO 81419-0161 970.872.3874 <br /> Jay Creek L LC P.O. Box 161 Hotchkiss, CO 81419-0161 970.201 .9331 <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 /> 2- 1"1 20 22— <br /> Signaturtgof Permittee, Operator or their uthorized agent Date <br /> Important: In accordance with Rules 4.14.2L) 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 /> MmmisRelea Requesffo—20Sep2017 <br /> Page 2 of 2 <br />