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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Release, Acreage Reduction, and Suretv Reduction Notices Checklist <br />C ♦ County Commissioners <br />Specify County: JoA I <br />❑ ♦ Soil Conservation District <br />Specify SCD: <br />M♦ Land Owner(s) <br />Name: Jet c. c4 �f lei rk <br />Address: P.O. f3cjK 76 7 <br />111.0-et-di , CC) 8 I4V33 <br />5R -oc <br />Up p$�ctiAC.t <br />t� ♦ Water Resources (If there is exposed groundwater) EPS Circle One: (2) <br />♦ - Receive one paper copy of Application form, Legal Description and Location Map <br />N <br />