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a <br /> Operator(If Other than Permittee): C--7 CAL VVL 0VN <br /> C. <br /> Permittee Representative: <br /> Certified Mail# �L,Lj t () 0 0 0 1 L4 q 5­6 <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 /> 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 accorda wi h e Rules and all applicable requirements under the Act." <br /> r <br /> Signatur i t , Operator or their authorized agent Date <br /> Important n accordance with Rules 4 14 2(a) and 41710) This release request must be submitted to the <br /> Division via certified mail and separate om any other correspondence to the Division. <br /> MineralsRelemeRequesfform 20Sep2017 <br /> Page 2 of 2 <br />