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Operator (If Other than Permittee): <br /> Permittee Representative: Rob Englehart <br /> Certified Mail # 7018 0040 0000 5100 1366 <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 /> 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 /> 10 <br /> Signature of Permi ee, per for or their au ' d agent Date <br /> Important.- In accordance with ules 4.14.2 a and 4.17.1 3 This release request must be submitted to the <br /> Division via certified mail and eparate rom any other correspondence to the Division. <br /> MineralsReleaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />