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41 <br /> Operator(If Other than Permittee): <br /> Permittee Representative: <br /> Certified Mail # 1 <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 /> nV55 co 9093a 7/9 5115-01?Da <br /> 3/550Je. W.2 41e, 7/9-5�/ 339 <br /> 3/550 t e.ti��, (' 808.33 7/9-5�/-a33 9 <br /> /5375.<''c"Awy. Zwil (14 80,?35 1//-"1-4-1' 07 <br /> a54 �r:r� i `. � �+s, C�0 ?21,70? 7/9- 37 <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 /> A <br /> . © A a PQf <br /> Sighature o ittee, Operator or their authorized agent We <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 /> MineralsReleaseRequestForm Mep2017 <br /> Page 2 of 2 <br />