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Operator(If Other than Permittee): <br /> N1ARt i�j <br /> Permittee Representative: <br /> Co u,mtt A� .. i 0 6 s W Cv c�c.Pt,7 r4vc �I cc� , P. co 8'0A3 <br /> Certified Mail# O � s �� 3 <br /> In accordance with Rule 4. 7.1(2)the Operator shall include a 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 /> -P0 Eox )L!5 <br /> f=Ajgp(-t��r' ,Ca ; 0Ogg0 �3� - �03 <br /> IY1( tRL (�l�'�fTS ilf�cz dccilj) 0 <br /> W r43 641H aqQ CoTTWTA(L�:R�iL <br /> �0061) -Au7 F"r, , C-) �;x g�3 <br /> 1Vr=t\,`i GOACC T!D LF —tf -E KU--d MMN D A-ktA Ot,FRLAp-s 0lj <br /> WODCt Aj AUL 31 NS <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 /> 'to p " E I /k :G��n �19c�7VLa 1 t /& A&-zo <br /> Signature of Permittee, OpeiitoXor their authorized ag t Date <br /> Important: In accordance with Rules 4.14.2(aj and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> Nimaah ReleaseRegoestFocm 20Sep2017 <br /> Page 2 of 2 <br />