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Operator(If Other than Permittee): <br /> Permittee Representative: Tim Loncarich <br /> Certified Mail # Yr ,51 o-+16 J j T1 14313 5c� <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 /> David Mollenberg 1465 Highway 141 White water Co, 81527 775-240-5741 <br /> Craig and Cynthia Reid 1533 Highway 141 Whitewater Co, 81527 970-261 -5715 <br /> JAK Ventures LLC PO Box 1708, Dillion Co, 80435 970-310-0320 <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 /> at of Pe e, erator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MineralsReleaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />