Laserfiche WebLink
Operator(if Other than Permittee): <br /> Permittee Representative: Jason Klds_t_O_n <br /> Certified Mail #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-10 Gcxvcr <br /> 70Y`GrO (,tcrtd Snr�St�tirtr+is U.G 295'3 5 . 1�eor`ia.Sr+. .5u.�` 200 <br /> C-0 SOON <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 /> 11/17/2022 <br /> Signature of Permittee, Operator or their authorized agent 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 sCparale from any other correspondence to the Division. <br /> Mu�elalsRckucRcyustFurm Mcp2017 <br /> Page 2 of 2 <br />