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Operator(If Other than Permittee): <br /> Pertnittee Representative: Ken Coulson <br /> Certified Mail# <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 /> CDOT 10601 W. 10th St., Greeley, CO 80634 970 350-2157 <br /> RANDY KIRTRIGHT 260 SE Frontage Rd. Johnstown, CO 80534 970-412-9952 <br /> OBRIAN LIVING TRUST PO Box 920, Johnstown, CO 80534 970-218-7326 <br /> [n 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 /> Signature of 'ermittee, Operator or their authorized agent Date <br /> IWLi rtant;_In accordance with Rules 4.14.2rai and 4.17.1 t3! This release request must be submitted to the <br /> Division via certified mall,and.separate_irom any other corres,,ondence to the Drvzsio:2._ <br /> UfineralsRticaseReyur,�iFo m VSepN17 <br /> Page 2 of 2 <br />