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Operator (If Other than Permittee): � <br /> Permittee Representative: (?] }- Ohns <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 /> 1�1 Cr�rn en►sH N esi ?6u dm &nv o n ura eu la bLt IJQ- e V6( <br /> 3y'!I vot Co Sa512 <br /> '�r,,n�i�u fl'wS 6 Phi► « <br /> r. (a~�Sh <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 /> ,� , -ZL 7 <br /> Signa a Permitte , 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 separate from any other correspondence to the Division. <br /> MmeralsReleaseRequesfform 20Sep2017 <br /> Page 2 of 2 <br />