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Operator(If Other than Permittee): 14k. W a-4-4-3 <br /> Permittee Representative: a i Ck. <br /> Certified Mail# <br /> 7013 30.20 0000 Al(„t GB/R <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 /> e- 7,4„,.s+ /173 1.4 PowI/, w ' '.2 1/3r 307-a rd -0 Va <br /> G/D -con's FreA,CL <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 /> I(/3/0211 <br /> ignature of Permittee, 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 /> MmeralsReleaseRequestFurm 20Sep2017 <br /> Page 2 of 2 <br />