Laserfiche WebLink
Operator(If Other than Permittee): <br /> Permittee Representative: Michael Toelle <br /> Certified Mail# 7019-2280-0000-5304-7699 <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 /> Holcim (US) Inc. 3500 Highway 120, Florence, CO 81226 (719) 288-1443 <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 /> � � �/."'it �, / ZU ZaZ3 <br /> Signature of Permittee, Opera or 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 /> Min=IsReleweRequestFom Mep2017 <br /> Page 2 of 2 <br />