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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Release, Acreaj4e Reduction, and Suretv Reduction Notices Checklist <br />Cl ♦ County Commissioners <br />Specify county: Cone - oP <br />C�" ♦ Soil Conservation District <br />Specify SCD: Ca ne � �s <br />C�' ♦ Land Owner(s) <br />Name: At,, R060S <br />Address: P^ 6- lox z 12- <br />A4- tortj I co g11Z0 <br />R� -or <br />P1 t <br />/2o%cns <br />N1�Z00i -0�3 <br />CompletL 4r <br />.(i«g C11-414 <br />❑ ♦ Water Res ourceS (If there is exposed groundwater) EPS Circle One: Y <br />♦ - Receive one paper copy of Application form, Legal Description and Location Map <br />0 <br />