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Operator(If Other than Permittee): same <br /> Permittee Representative: Julie Miku18S <br /> Certified Mail # 7006 0810 0000 8144 6737 <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 /> Martin Marietta Materials, Inc 1800 N Taft Hill Road, Fort Collins, CO 80521 970-407-3631 <br /> Joe&Joy Scalese 2790 South Road, Pueblo, CO 81006 719-240-2272 <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 /> SilKnature of Permittee, Operator of 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 /> MmeralsReleaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />