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Operator(If Other than Permittee): <br /> Permittee Representative: <br /> Certified Mail# �2- COL)L) C(r—r E�T-Kl -:t:3'5 <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 /> &IA(�(Svc �LV-4; <br /> ICU E-- LcSso 40 C <br /> l� �; <br /> In accordance with Rule 4.17.1(4), if re csting a partial acreage release the Operator or their agent MUST sign that <br /> they have complied with the followi g staters . 'All applicable portions of the Reclamation Plan requirements <br /> have been satisfied in accordance with these Rules an 11 applicable requirements under the Act." <br /> g - 4 zz <br /> tgnat re of Perms ee, Operator or their authorized) nt Date <br /> Im orta t: In accordance Kith Rules 4.14.2 a an .17.1 3 This release request must be submitted to the <br /> Divisio via certified mail and separate rom any other comes ondence to the Division. <br /> K m 1,R0%m,cReyuc,tFunn 20Scp201" <br /> Page 2 or 2 <br />