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Operator(If Other than Permittee): NSA <br /> Permittee Representative: Jason Burkey <br /> Certified Mail # <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 /> Ruth Skelton PO Box 125 Norwood, CO 81423 970-596-3889 <br /> MT Nest Revocable Trust PO Box 223 Norwood, CO 81423 925-842-1000 <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 /> 6000--� 02-02-2023 <br /> Signaturpllf Permitt , 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 fi-om any other correspondence to the Division <br /> MmeralsReleaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />