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Operator (If Other than Permittee): <br /> Permittee Representative: Tom Brubaker <br /> Certified Mail# ?aa7, 0y 4d OOoZ• 0? ,r 2 (4. <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 /> Valley Community Church 27435 Rd. 22.75, Rocky Ford, CO 81067 719-254-4055 <br /> Valcrete, Inc. 22663 Hwy 50, Rocky Ford, CO 61067 719-254-7461 <br /> Martin Pipe and Steel, Inc. 22537 Hwy 50,Rocky Ford, CO 81067 719-254-4020 <br /> Dwight and Julie Proctor 24625 Rd 23, La Junta, CO 81050 719-384-8611 <br /> City of Aurora Att: Jeff Hanna 1515 Alameda Pwky., Suite 3200,Aurora, CO 80012 303-739-7000 <br /> Otero County Road and Bridge P.O. Box 551 , LaJunta, CO 81050 719-384-3092 <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 /> 6/21 /2022 <br /> Signature of Permittee, 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 from any other correspondence to the Division. <br /> MmeratsReleaseRequestForm 20Sep20I7 <br /> Page 2 of 2 <br />