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Operator(If Other than Permittee): <br /> Permittee Representative: Angela Bellantoni <br /> Certified Mail# 1D2 D 0000 6 gad ?--1 73 <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 /> US Forest Service 810 Front Street, Leadville, CO 80461 (719) 836-3871 <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 /> � zl�l <br /> Signature f Permittee, erator or their authorized agent Date <br /> Important.- In accordance with Rules 414 2(a)and 4.17.1 L) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MineralsRelea Requesfform 20Sep2017 <br /> Page 2 of 2 <br />