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DocuSign Envelope ID.D465B1C9-DB77-4885-A4DF-OF13558CDA23 <br /> Operator(If Other than Permittee): <br /> Permittee Representative: Katie Blake <br /> Certified Mail # 7017 2400 0000 4071 1224 <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 /> Jim R. Chapman Jr. PO Box 944, Cripple Creek CO 80813 719-661 -5729 <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 /> Co«uSlgmd by: <br /> 14-Dec-22 <br /> 5A3D013B629W, B <br /> Signature of Permittee, Operator or their authorized agent Date <br /> Important.- In accordance with Rules 4.14.2(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 /> M—ralsRd,aseReq-stForm 20Sep2017 <br /> Page 2 of 2 <br />