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Operator(If Other than Permittee): <br /> Permittee Representative: <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 /> <,LNA PD�F:tT SCr-0—Lt-& 2A. 2 11 1--AkPt,+t to G VA) 7J9- 936 -2b 3 <br /> ter tfc`D L 4 Z.3 id lk 6 rave �01 l V70 p 01 ? <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 /> C—�L , 'or,/I 44� <br /> Signaptre of Permittee, Ope r or their authorized agent Dat <br /> Important: In accordance with Rules 4.14.2(a)and 4.17.1 Q This release reduest must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division <br /> MinemisRelemRequestForm Mep2017 <br /> Page 2 of 2 <br />