Laserfiche WebLink
Operator(If Other than Permittee): <br /> Permittee Representative: �an�y ROg@PS <br /> Certified Mail# 7017 2400 0000 5183 9795 <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 /> Washington County 150 Ash Ave Akron CO 80720 970-345-2701 <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 /> 3/28/2022 <br /> ignature of Permittee, Operator or their authorized agent Date <br /> Important• In accordance with Rules 4.14.2L) and 4.17.1 L) This release request must be submitted to the <br /> Division via certif ed mail and s�arate from any other correspondence to the Division. <br /> MineralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />