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(D Jun 17,2021 20:02(UDC) From: WWW.FAX.PLUS To:+13038328106 2 of 2 <br /> 14k <br /> OperatofIlf Other than Permittee): <br /> Pernii(ted Representative: (Y\&7k- CoS_r` a n 10 Cr <br /> e <br /> Certified�Mail # <br /> .E. <br /> in accordance with Rule 4.17.1(2)the Operator shall include the names,addresses and phone numbers of all <br /> J . <br /> owners of record to the affected land. Please attach additional sheets for this information if required. <br /> Name Address Phone Number <br /> 906b7 C,,(�- ( C6 �� -� �� (-7(a� 336' 3� I3 <br /> BEoSz <br /> E4 C-715� 8 <br /> +�1eSa �715) <br /> 4 <br /> e <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 cbmplied with the following statement: "All applicable portions of the Reclamation Plan requirements <br /> have beeq%jisfied in accordance with these Rules and all applicable requirements under the Act," <br /> I� <br /> Signatu,e f Permitte Oper or their authorized agent Date <br /> Import nk.In accor nce with Rules 4.14.2(a)and 4.17.1(3) This release request must be submitted to the <br /> Division tei certified mail and separate from any other correspondence to the Division <br /> AtmcnlaRc lucclform 20ScpZ0 t� <br /> A <br /> r <br /> Page 2 of 2 <br /> id <br />