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Operator(If Other than Permittee): <br /> Permittee Representative: Anne Beierle <br /> Certified Mail # 1 b ) I ZI1 0 0()00 0 (vv 011 <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 /> Glenda Guanella P.O. Box 128 Empire, CO 80438 303-569-2839 <br /> Sally Buckland P.O. Box 56 Empire, CO 80438 303-569-2988 <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 /> Anne Beierle Digitally signed by Anne Beierle 10/21 /2 022 <br /> Date:2022 10.21 13:36:27-06'00' <br /> Signature of Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14?(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 /> bin—IsReleaseReques[form 20Sep2OI <br /> Page 2 of 2 <br />