Laserfiche WebLink
Operator(If Other than Permittee): N/A <br /> Permittee Representative: Grant Johns <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 /> Phil Camenish 29839 Poudre Canyon Road Bellevue, CO 80512 Unavailable (deceased) <br /> Family/Trust of Phil Camenish 29839 Poudre Canyon Road Bellevue, CO 80512 Unavilable <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 /> /ir <br /> ,. . :M A_ o‘. l b.262 Lk <br /> Signa re of 'ermittee, Operator or.. ieir 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 /> MineralsReleaseRcquestForm 20Sep2017 <br /> Page 2 of 2 <br />