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Operator(If Other than Permittee): <br /> Permittee Representative: }4ñ 1,001)a5 <br /> Certified Mail # 39 07I 0 5-70 l ooS 30T-fl- 9 6 <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 /> LAj <br /> e.5Ti&1KI— OI(Ai U 1 piaMonor i(be Ci2Ae CSs(rRrY.-t-,CCS <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 /> • slag �a <br /> Signature of Permittee, Oper a or their authorized agent Dat <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 /> MmeralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />