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Operator(If Other than Permittee): /� <br /> Permittee Representative: „ `��11 <br /> Certified Mail# ,1� <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 /> ef,(3( <br /> Ja• 0_ it ice S lP® - 50x t�i vd r� 303-�<C'3 7Z-.q <br /> 1 <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 /> Sign of a At , era or their authorized agent p ea ea ( ^ (720� <br /> I rtant: In acco ance with Rules 4.14.2 a and 4.17.1 3 This release re uest must be submitted to the <br /> Division via certi zed mail and se rate rom an other corres ndence to the Division. <br /> MioaahRekascRequeaFam 20s,20t7 <br /> Page 2 bf 2 <br />