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Operator(If Other than Permittee): <br /> Permittee Representative: John Warren <br /> Certified Mail # 9589 0710 5270 1281 5952 37 <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 /> Connell L LC 7785 Highland Meadows Pkwy,Suite 1,Fort Collins CO 80528 (970) 223-3151 <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 . ' . the following statement: "All applicable portions of the Reclamation Plan requirements <br /> have been satis -d in accordance with these Rules and all applicable requirements under the Act." <br /> Sign. . e of Permittee, Operator or their authorized agent ate <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,nail and separate from any other correspondence to the Division. <br /> MmeralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />