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Operator(If Other than Permittee): n <br /> Permittee Representative: <br /> Cet4 <br /> �r►occ`r r`Po-A ferst 14 ET 'ZCaS 09 O -,S tog U <br /> In accoince 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 /> d) or (�3e DgoS \ 0\& 0 <br /> pwN'tj'Quc3 a. �3tn) 35 ze- <br /> �Ir L-� 8Cio03 <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 /> Signature of Permittee, Operator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.1() This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MmeralsRelemeRequesfform Mep2017 <br /> Page 2 of 2 <br />