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Operator(If Other than Permittee): <br /> Permittee Representative: RP �}m) P t- k , 1 QWPSOYJ - Pgtts WU,1-` PtftY PRAt <br /> Certified Mail 4 Pot,t`r 1Vti O cs M( c7: <br /> TO)s fsa) Ql -,-2 <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 /> EC-=ARy pik NET&c)POU K) Ph, BOY, t k?3, L 9v R cd 90 t1 303-RcTo 7e�( <br /> PlS'�t2lc�' <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 /> /,///Z <br /> l iMkW-f PARK tIETPOPOLit © /1-90(01> <br /> 111'131"of Permittee, Operator or 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 /> MmemisRelemeRequesffonu ZOsep201' <br /> Page 2 of 2 <br />