Laserfiche WebLink
Operator(If Other than Permittee): N/A <br /> Permittee Representative: Jason Burkey <br /> Certified Mail# —I o n 210,20 Dodo„L-?33 gq$5 <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 /> Thomas Latham 1915 Hwy 6, DeBeque, CO 81630 970-210-1832 <br /> Chevron USA, Inc. PO Box 285, Houston, TX 77001 925-842-1000 <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 /> � 09 1/ 6/2024 <br /> Signatur of Permittee,Operator or their authorized agent Date <br /> Important: 1n accordance with Rules 4 14 2(a)and 41710) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division <br /> Wwm1eRekwRcgkwm 4mi Mev2017 <br /> Page 2 of 2 <br />