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Operator(If Other than Permittee): NA <br /> Permittee xepresentative: Dan Tucker, 719-406-2852, dan@agraco.net <br /> Certified Mail# <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 /> Mtn. States Sheet Metal Co 27350 CO 96, Pueblo, CO 81001 7� 9-948-3195 <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 /> �-- <br /> �� l b �o <br /> Signature of Pertnittee, Operator or their authorized agent Date <br /> Important: 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 frotn anv other corre�ondence to the Division. <br /> MmenlsRelcaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />