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Operator(If Other than Permittee): <br /> Permittee Representative: Jodi Schreiber <br /> Certified Mail # -7O9 04-1-t p 0000 $3-3Lc, (g-13 <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 /> Edmundson Ranches LLC PO Box 128, Walsenburg, CO 81089 719-859-0069 <br /> Colorado State Land Board 1127 Sherman Street, Denver, CO 80203 303-866-3454 <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 /> r • <br /> 40 / k 7/22/2025 <br /> S.~ .re of '--^'Tr=";S perator or their authorized agent Date <br /> mportant: 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 mail and separate from any other correspondence to the Division. <br /> MineralsReleaseRequesoForm 20Sep20I7 <br /> Page 2 of 2 <br />