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Operator(If Other than Pennittee): <br /> Permittee Representative: <br /> L.r 7 is e� (na�ZS epvler <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 /> C-CAOCCASO ac vi Lei 11,2-7 en, r 303 <br /> Cn SOZo3 <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 4tirre of Pe., ittee operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(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 /> MmeraIaRekaseRequcstForm 20Sep20I7 <br /> Page 2 of 2 <br />