Laserfiche WebLink
Operator (if Other than Permittee): <br /> Permittee Representative: Jodi Schreiber <br /> Certified Mail 7020 2450 0002 1856 8376 <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 /> Darren & Donna Buss 12426 US HWY, Howard, co 81233 719-371-4114 <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 /> �_____74 . 7/19/2022 <br /> Sign re a erator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.1O This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MmeralsReleaseRequ (form 20Sep2017 <br /> Page 2 of 2 <br />