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Operator (If Other than Permittee): <br /> Permittee Representative: Julie A Welte, VP of Mining & Environmental, Summit Brick <br /> Certified Mail # 7019 2970 0000 4461 8217 <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 /> Michael & Angela Diehm 7383 S John Dein Lane, Ft.Calhoun, NE 68023-5137 402-850-71 54 <br /> Christopher McCoy 8606 Holman Circle, Arvada, CO 80005-5957 No Disturbed Area on Land <br /> Ramon & Gloria Laughter 3591 Oak Meadow Drive,Colorado Springs,CO 80920-2415 No Disturbed Area on Land <br /> SLAA 'SoZ113 E M4in Sk. , Cg-san City Co TIZ12- -71 l— ZG9 <br /> CBL A A c-l-e-A <br /> Nv�- ge; 12¢ lc�seol <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 fVWAUL.4�AC, CED 11 /01 /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 om any other correspondence to the Division. <br /> MineralsReleaseRequesfform Mep2017 <br /> Page 2 of 2 <br />