Laserfiche WebLink
Operator(If Other than Permittee): <br /> Permittee Representative: Ben Jordan <br /> Certified Mail# -YPAA p cp O--� <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 /> Lisa C rave n e r 5095 Rodgers Dr Hartsel, CO 80449 719-839-1730 <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 /> Digi6C=signedjo Ben Jordan 10/25/2024 <br /> Ben Jordan DN;G=oS,E=bj alter,C z=Ben Jordan <br /> n Zak Dirt Inc., <br /> OIJ�;.Project Manager,CN=Ben Jordan <br /> Dato3 2024.10.2511:31:12-06'00' <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 /> MineralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />