Laserfiche WebLink
Operator(If Other than Permittee): Ttw-e-1 I't. 4 <br /> L <br /> Permittee Representative: T e �'� l-�7'1-CY-- <br /> Certified Mail # <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 /> �72 Z <br /> rng�cws C_YL "C6 C) <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 /> 1 Cj r <br /> S' ature of Permittee, perator or their authorized agent Date <br /> Important: In accordance with Rules 4.14.2(a) and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> Min L%Rc1mscReques1Foim Mcp201- <br /> Page 2 of 2 <br />