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I tperator(If()ther than Permittee): <br /> I Pennittee Representative: ._-- <br /> ��,�� 1, <br /> Certilied Mail 4 <br /> In accordance«ith Rule 4.17.1(2)the Operator shall include the names,addresses and phone numbers of all <br /> ! o%%ners of record to the affected land. Please attach additional sheets fir this information if required. <br /> Name Address Phone Number <br /> 0)aruct0 (5)ulc ctrc�, B octrc ��-1L__�—J 21 S� <br /> _gam pcwr -rn _3 lo5`L1 U s,,,,gA �yy,, 3 O LY- �� 1 <br /> ru..2-hla) co d po(P <br /> In accordance%0h 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%pith these Rules and all applicable requirements under the Act." <br /> Signature of Permittee,Of 1crator or their authorized agent Date <br /> Important: In accordance with Rule.v 4.14.2(a)an(I4.17.10) This release request must be submitted to the <br /> Division Via certifietl moil and separate from am,other correspondenet,to the Division <br /> 1! 41'xrai,Rrtcir.cReyucuh �m:".+ej:'1�7 <br /> Pape 2 o1 Z <br />