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Operator (If Other than Permittee): <br /> Permittee Representative: s-�� CDUJMA_ f <br /> Certified Mail # —4-09,2 oq/d flvDI 9-:t ,p �-��8 <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 infonnation if required. <br /> Name Address Phone Number <br /> (BEMOU5 QUA&) WEN &17-H I;zk4O Cang-mi RAic- 161-W7-j <br /> WOO DILAND �>UK'I CO S109163 <br /> Toe-pogkj s (A-601T PDR) FO e©x 413 <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 /> a <br /> Signature of Permittee, Ope for r their authorized agent 44—Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.1(3) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> %Iin—IsRele—Reyuesfform 20Sep2017 <br /> Page 2 of 2 <br />