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Operator(If Other than Permittee): <br /> Permittee Representative: 6,4t <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 Phew 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 ules and all applicable requirements under the Act." <br /> Signature of Permitte , Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.21a) and 4.17.1 Q) This release request must be submitted to the <br /> Division via certi ted mail and separate from any other correspondence to the Division. <br /> MinemisReleaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />