Mine Release Request

RELEASE REQUEST FORM
Instractions: Fll out this form ifalI mining has ceased,you have LQ ipleted all of the regtftred
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 Duality Section
regional Office serving your area or to:
N_ C. Department of Eavironm elm t and Natural Resources
Land duality Section
1612 Mail Service Center
Raleigh, PVC 27693-16I2
OPERATOR: � c� N l L t'
ADDRESS. — �..�� �-� � ��. _ �i�Ylc51� S
QS
MnE NAME-
PERMIT NO.;
COUNTY-
TOTAL ACRES RECLAIMED:
TAILINtiSPONDS; 0 STOCKPILES: ✓ 'WA TEPI.LUS:
PROCESSING PLAINT: 0 ACTIVE MINE AREA; 6
1 have completed all of the required reclamation work at the above referenced site. l ant
hereby requesting to be released from the conditions ofthis mining permit and that the posted
bond be returned to my attention_
Signed
Title_ M09,Y' _
Date zoz
9/03