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Operator(If Other than Permittee): N/A <br /> Pertnittee Representative: JaSOC1 Burkey <br /> Certified Mail# 7- �J 1. <br /> In accordance with Rule 4.17.1( )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 /> 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 /> 12-14-2022 <br /> Signature Permittee, pe or or their authorized agent Date <br /> Important: In accordance with Rules 414 2(a) and 41710) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division <br /> MinemisRekuaRequestFomt Mep2017 <br /> Page 2 of 2 <br />