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Operator (If Other than Pennittee): <br /> Permittee Representative: ,C, , <br /> Certified Mail # <br /> In accordance with Rule 4.17.1(2) the Operator shall include the naives, 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 /> Chad Th es 7l0$Sf IeQ, lL L u�ons 303-3 00 --7/0 0 <br /> L�-►�,� 1 Zle�'S �B�I��'��Sf�,, �n y� <br /> Coy SaaoS <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 /> Cvo l9 / Q <br /> Signatu e of Permittee, Operator or their authorized agent <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.10) This i-elease reduest must be submitted to the <br /> Division via certified mail and separate from anv other correspondence to the Division. <br /> M m—IsRele,—ReyuemFurm'_0Sep2017 <br /> Page 2 of 2 <br />