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Operator (If Other than Permittee): <br /> Permittee Representative: Paul Ainsworth <br /> Certified Mail # - 0 r ;�- —dta) p— 000 a -:)LSl q - ��) <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 /> Continental Materials Corporation 440 S LaSalle St#3100 Chicago, IL 60605 31 2-541 —7222 <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] I A i/e-( <br /> hc)� <br /> Signat e o Per ' e, 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 /> MineralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />