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Operator(If Other than Permittee): <br /> Permittee Representative: <br /> Certified Mail # 7019-0160-0000-2621-3789 <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 /> Robert J & Rozann Safranek P.O. BOX 970 Limon, Co. 80828 719-775-9445 <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 /> Digitally signed by Ty Stogsdill <br /> DN:cn=Ty Stogsdill,o=Lincoln County,ou=Land Use,email=lclanduse@esrta.com,c=US 6-30-22 <br /> Date:2022.06.3011:11:47-06'00' <br /> Signature of Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MmemisReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />