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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 /> A <br /> 4j'j, <br /> Vli � ` Crd .5 3 ('LCLM 97��7?r/ <br /> - <br /> iat <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,f l,t 2(a) and 4 171(31 This release request must be submitted to the <br /> Division via certified mail and separate om any other correspondence to the Division <br /> AI—AsRe1ea Reque ff—?USep20I7 <br /> Page 2 of 2 <br />