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L <br /> Operator(If Other than Permittee): <br /> Permittee Representative: Rory Hale, Public Works Director <br /> Certified Mail# - �q0 CX�OI �q� © 866a <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 /> Bob Thurston 3496 CR 137, Ramah CO 80832 719-541 -2027 <br /> Mailing- 3011 CR 137, Rush CO. 80833 <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 /> ;;11`4, <br /> 8/25/2022 <br /> Signature Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.1 U This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> M—IsReleaseReque(form 20Sep2017 <br /> Page 2 of 2 <br />