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Operator (If Other than Permittee): <br />Permittee Representative: <br />Certified Mail # 7017 1450 0001 7878 0299 <br />In accordance with Rule 4.17.1 a peraEor s a include t e 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 <br />Address <br />Phone Number <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 accordpee with these Rules and all applicable requirements under the Act." <br />Signature of Permittee, Operator or <br />-"L v <br />agent Date <br />Important: In accordance with Rules 4.14.2(a) and 4.17.1 Q) This release reguest must be submitted to the <br />Division via certified mail and separate from any other correspondence to the Division. <br />Minua1.A9La Vpjft9F0fMMcp2nl7 <br />Page 2 of 2 <br />