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Operator(If Other than Permittee): L.G. Everist, Inc. (Matthew Noteboom, Vice President) <br /> Permittee Representative: Lynn M. Shults (Imshults@Igeverist.com, cell-303-514-2778) <br /> Certified Mail # 7020 0090 0001 0134 6751 <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 /> Freddy and Lisa Dodge 11586 County Road 18 303-912-9604 <br /> Fort Lupton, CO 80621 (F Dodge) <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 /> ct___ <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 />