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Operator(If Other than Permittee): <br /> Permittee Representative: Ip& \SPAM� r <br /> Certified Mail# 9589 3713 5273 3451 1377 10 <br /> In accordance with Rule 4.17.1(2)the Operator shall includ 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 A4dress Phone Number <br /> b 13tA MO 0►rL 't'p Box S-1.r- (D 43-505-� <br /> INJ <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 e o PermRtee, 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 /> MinersIsRcicascRcquestForm 20Scp20 17 <br /> Patee2of2 <br />