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Operator(If Other than Permittee): n�a <br /> Permittee Representative: Betty KPaCht, White River Consulting <br /> Certified Mail# ?d!5 Ol��D DDD 7 925g 350� <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 /> ���,C�O C R S V�B c��1r`� CD <br /> Brian and Sheryl Brock P.O. Box 11235 Prescott, AZ 86304 92$-ggg-2� $2 <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 /> ,�- -����f� �,-��,- ..�__._ 11/3/2021 <br /> Signature of Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.1 L) This release reguest must be submitted to the <br /> Division via certified mail and separate rom any other correspondence to the Division. <br /> MmeralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />