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Operator (If Other than Permittee): <br /> Permittee Representative: n/ <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 /> Z en e y�e�m e,+r' t� c) box 59 o , N u clk CD °I`10- <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 /> Si ature of Permittee, perator or their authorized agent Date <br /> Important: In accordance with Rules 4.1.1.2(a) and 4.17.1(3) This release request must be submitted to the <br /> Division via certified mail and separate°from any other correspondence to the Division. <br /> MmeralsReleaseRequestlorm 10Sep1017 <br /> Page 2 of 2 <br />