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Operator (If Other than Permittee): <br /> Permittee Representative: 1-?2 <br /> Certified Mail # <br /> In accordance with Rule 4.17.1(2) the Operator shall 'include the :lames, 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 /> / r mac% Us e Z e-A CAF37 <br /> 3c - Sl /G s Y <br /> _fie pt"ral 13 <br /> v <br /> 3�3- �l7 /327 <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 /> el <br /> Signature of Permittee. Operator or their authorized agent Date <br /> ImPortunl• In accordance with Riles 4.14.2(a) and 4.17.1 Q) This release request must be submitted to the <br /> Division riu certified mail and separate Mom any other corre_s.1)ondence to the Dhjyion. <br /> .4Tmcrdsltcicasc Rcyuca Fora❑:oScp^017 <br /> lla"rc 1 42 <br />