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Operator (If Other than Permittee): <br /> Permittee Representative: <br /> -- - -------------------- <br /> Certified Mail # <br /> -- ---------------------------------------- ----------- <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 /> 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 /> ►�olr'PernniQlttee, Operato or their authorized agent Date <br /> Important: 117 accordance with Rules-4,14.2(a)_and 4.171(31-This release request must be submitted to the <br /> nivision via certi led mail and separate Yom any other correspondence to the Division.- <br /> \tmem LRcica.e Requcdl nun'-OSep'ol! <br /> Page 2 of 2 <br />