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Operator(If Other than Pertnittee): <br /> Permittee Representative: Heath Higgins <br /> Certified Mail # 9589071052700925415535 <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 /> Jamie Bradshaw 15035 Road 20, Cortez, CO 81321 970-739-0155 <br /> Wayne Rogers 19282 Road S, Cortez, CO 81321 970-739-0682 <br /> Michelle Welsch 2080 Norwood Road, Boulder, CO 80304 303-442-5250 <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 /> 7 k( "7 <br /> 05/07/2025 <br /> Signature of Permi e, Operator 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 certt Lied mail and separate from any other correspondence to the Division. <br /> MineralsReleaseRequesfform 20sep2017 <br /> Page 2 of 2 <br />