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Operator(If Other than Permittee): <br /> Permittee Representative: Brent Tamburelli <br /> Certified Mail# 9589 0710 5270 1283 8923 34 <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 /> Nicole Tamburelli 6(pm ; ,% �: `l,�,r �C4, 719-859-0435' <br /> 7 <br /> (1((Vad S/'r (Y)r <br /> 6'( <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 ll- 5plicable requirements under the Act." <br /> 02-15-2024 <br /> Signature of Permittee,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 from any other correspondence to the Division. <br /> MmeralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />