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Operator(If Other than Permittee): <br /> Permittee Representative: <br /> —50n01 +-ANDO M,002i� <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 /> Rio Grande Silver, Inc. 625 USFS Road 504. 1A 208-769-4125 <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 /> SOP O II/L(/Zc77 o <br /> Signatur!/of Permittee, G'.erator or their authorized agent Dat <br /> Import., t: In accords ce 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 /> MineralsReleaseRequestForm 20Sep2017 <br /> Page 2 of 2 <br />