SIGNEDMinereleasereqform 042623

RELEASE REQUEST FORM
Instructions: Fill out this form if all mining has ceased,you have completed all of the required
reclamation work and you wish to be released from the conditions of your permit. Retain the
pink copy for your records and return the yellow and white copies to the Land Quality Section
Regional Office serving your area or to:
N. C. Department of Environment and Natural Resources
Land Quality Section
1612 Mail Service Center
Raleigh, NC 27699-1612
OPERATOR:
ADDRESS:
MINE NAME:
PERMIT NO.:
COUNTY:
TOTAL ACRES RECLAIMED:
TAILINGS PONDS: STOCKPILES: WASTEPILES:
PROCESSING PLANT: ACTIVE MINE AREA:
I have completed all of the required reclamation work at the above referenced site. I am
hereby requesting to be released from the conditions of this mining permit and that the posted
bond be returned to my attention.
Signed Z C)a-, a
Title
Date 5/4/23
9/03