PLFD 0010A (Rev. 11/2004)
Public Lands and Forests Division 3rd Floor, South Petroleum Plaza 9915 – 108th Street Edmonton, Alberta T5K 2G8 Phone: (780) 427-3570 Fax: (780) 422-4251
Request for Letter of Clearance
(Operator's Name, Address, Phone and Fax Numbers) I, (Name) for (Lease/Licence/Reservation No.) on (Legal Description) hereby apply for a Letter of Clearance
as outlined in yellow in the attached plan. (Please complete a plan and attach.) If filing electronically, bold area to be certified. This application is my verification that: All improvements have been removed Brush disposal is complete Backsloping is complete Recontouring is complete Revegetation is complete (80% or greater revegetation) OR This is my verification that no entry was made on these lands.
(Clean-up Contractor's Name and Address) The required reclamation was completed on (Date) and I inspected this site on (Date) and found all conditions to be in a satisfactory condition which should permit the issuing of a Letter of Clearance. I understand that if the department finds the reclamation satisfactory, and if the operator is not indebted to the department, the security deposit will be refunded. Date _____________________________ Signature of Applicant
The information requested on this form will be used to authorize use of public land. This information is requested in accordance with the Public Lands Act, and is protected by the provisions of the Freedom of Information and Protection of Privacy Act. For further information, contact the Public Lands & Forests Division at (780) 427-3570.