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Operator(If Other than Permittee): 101C1.Af RI/AV ( kk L , UL� <br /> Pctmittce Representative: e 0 LAOPooic9 <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 /> Avd0 I• �o aqo O c, �- SI. 1 (qo) ' -tl <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 sztisfied in accordance with these Rules and all applicable requirements under the Act." <br /> 6A004-6 <br /> Si ur o ermittee,Operator or their authorized agent Date <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 /> MeeeraWleleuelteepeestFonema.p2on <br /> Page 2of2 <br />