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1 <br /> Operator(If Other than Permittee): <br /> Permittee Representative: Amy Brooks, COO <br /> Certified Mail# ;70 /( _ Q ;70(0 _ 6'100a -- 0 Z JS <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 /> Robin Hayes 1844 Hwy 144 Orchard, CO 80649 970-590-0971 <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 /> 0" &1°°v,,�2 12'1 Z zo 2-+ <br /> Signature of PernUttee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a,) and 4.17.1 L) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MincralsReleaseRcquesfform 20Sep2017 <br /> Page 2 of 2 <br />