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Operator(If Other than Permittee): N/A <br /> Permittee Representative: <br /> Jason Burkey <br /> Certified Mail # / 2 ) 2?Zb 0003 23lam )0,4 ? <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 /> Jocko Camilletti PO Box 249 Hayden, CO 81639 970-734-4714 <br /> Todd E. Camilletti PO Box 1262 Hayden, CO 81639 970-846-3864 <br /> CW H Properties 7785 Highland Meadows Parkway,#100 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 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 Perm- ee, Operator r their authorized agent Date <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 mail and separate from any other correspondence to the Division. <br /> MmoalsReleaseRequestFonn 20Sep2017 <br /> Page 2 of 2 <br />