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<br />Page 2 of 2 <br /> <br />Operator (If Other than Permittee): <br />Permittee Representative: <br />Certified Mail # <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 /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <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 /> <br /> <br /> <br /> <br /> <br />Signature of Permittee, Operator or their authorized agent Date <br /> <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 /> <br /> <br />MineralsReleaseRequestForm 20Sep2017