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Operator(If Other than Permittee): Same as permittee <br /> Permittee Representative: Juan COCoba 7022 0 410 0002 7228 5345 <br /> Certified Mail# CLt� 2 Z 2 qS. y S-- <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 /> Five Rivers Ranch Cattle Feeding LLC(Contact Name Juan Cocoba) 258 VV Hwy 50, Lamar, CO 81052 719 829 4841 <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: " 11 applicable portions of the Reclamation Plan requirements <br /> have been satisfied in accordance with these Rule d all applicable requirements under the Act." <br /> 3- 3 -- Z 3 <br /> Signature of PermitteV <br /> for or their authorized agent Date <br /> Important: In accord" 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 /> MmeralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />