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Operator(If Other than Permittee): <br /> L'Y1 pumj cc-'r dTl-} <br /> Permittee Representative: 5�-ftf� CCXL)j�lk� <br /> Certified Mail # :T019 dgg0 ©ail �t`1S I q bg(P <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 /> U�F5 sa[WBA K nlcup- D,STPIC t" co o4�fa Iq- s 76-�zo 1 <br /> I z�{0 c.U1TL�ti1TA-1 t.- -n2ti r�.. <br /> a-J4 �IUiJ NOUJ X-04,5DCMD RARKt Co $r.S'63 319 - ` 6 - oTy <br /> M 4E RM 2I&ItM RR THE <br /> GeD,,�ux`P LOP)e c hm, c.MC Asa-L;t�- <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 -P�1I E12D zz,, <br /> Signature of Permittee, Operai6r r their authorized agen Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and sWarate from any other correspondence to the Division. <br /> MnxralsRekawRequestForm Mep2017 <br /> Page 2 of 2 <br />