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Operator(If Other than Permittee): H o I ci m - MR, Inc. <br /> Permittee Representative: Pain Conrad <br /> Certified Mail# 7016 2070 0000 3223 2892 <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 /> City of Longmont 350 Kimbark Street Longmont CO 80501 303 776 6050 <br /> Diamond G Concrete Company PO Box 54, Longmont CO 80502 303 702 0708 <br /> Golden Farm LLLP PO Box 54, Longmont CO 80502 303 702 0708 <br /> RLSJ, LLC PO Box 54, Longnont CO 80502 303 702 0708 <br /> Costco Wholesale Corporation 9999 Issaquah Dr. , Issaquah WAS 98027 425 313 6549 <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 /> Paul Conrad Digitally signed by Paul Conrad <br /> Date: 2022.12.09 10:26:28-07,00' December 9, 2022 <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 /> MmeralsReleaseRequmfform 20Sep2017 <br /> Page 2 of 2 <br />