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Operator(If Other than Permittee): <br /> Permittee Representative: � ; ��h�ka& <br /> Certified Mail # 7020 1810 0000 1557 2676 <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 /> tlfhl Pattt"z <br /> -Id4 a� Ge- a-3 '� 19 -3S4 - Y4 !� <br /> Lo-.uvdl-- , ez FLoso <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 /> Oil <br /> ,� d- � 1� <br /> igna of Permittee, Operator or their authorized agent 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 certif ed mail and separate from any other correspondence to the Division. <br /> MiueralsRelcmcRequestForm 20Sep2017 <br /> Page 2 of 2 <br />