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Operator(If Other than Permittee): <br /> Permittee Representative: �l i ��� P ua �L , CI L,7)4� <br /> Certified Mail # <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 /> l/C �-�q 6 SUYI(. '446VA Ft 970 326, S-91� <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 /> Signature of Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MineralsRelemeRequesfform 20Sep2017 <br /> Page 2 of 2 <br />