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Operator (If Other than Permittee): <br /> Permittee Representative: <br /> JW i� ►�i - <br /> Certified Mail # <br /> 7014 z 4-2-0 0 001 LU'10 0 4-71 <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 /> A'YJXr � 3 I a 0 rl►°l - ­4�-1 l-pity <br /> 4AWA Coo XIa.3 <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 /> C-44/4,�, S�A , * -:� -06p/�ao.N-* <br /> Signable'ofTerm"I'tTee, 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 /> MineralsRelemeRequesfform 20Sep2017 <br /> Page 2 of 2 <br />