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Operator(If Other than Permittee): <br /> Permittee Representative: <br /> Certified Mail # Mla Q41-- <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 /> q�� <br /> �D ace novc�r, <br /> C�2(oo Nv.1Tos�v�ile �1 <br /> S os ; J � - �4a85�0 <br /> (-73 W. l�1- Rare <br /> d . (`) f))cl 11 q- �g8 �� <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 /> jhae bee satisfied in a nce with these Rules and all applicable requirements under the Act." <br /> CT <br /> gnature ee, Oper o or their authorized gent Date <br /> Important accordance with Rules 4.14.2(a) and 4.17.10) This release request must be submitted to the <br /> Division via certified mail and separate from any other correspondence to the Division. <br /> MineralsReleaseRequestForm 205ep2017 <br /> Page 2 of 2 <br />