<p> Surface Materials Reclamation Certificate Request SML, SMC, DRS and Associated Access (DLO)</p><p>Operations Division</p><p>Disposition Holder: </p><p>Address: Town: </p><p>Province: Postal Code: Telephone: </p><p>I hereby apply for a Reclamation Certificate for on (Lease/Licence/Reservation No.) (Legal Land Description)</p><p>This form, plan and payment must be submitted electronically to Electronic Disposition System (EDS). For EDS support email to [email protected]</p><p>This application is my verification that:  All improvements have been removed  Coarse woody debris has been managed to promote vegetation development and fine woody debris has been managed as per Directive - SD 2009-01 Management of Wood Chips on Public Land  Backsloping is complete  Recontouring is complete  Salvaged topsoil and subsoil has been replaced  Revegetation is complete as outlined in the Conservation and Reclamation Plan (C&R) or Conservation and Reclamation Business Plan (CRBP).</p><p>A fee of $400 by credit card is required.</p><p>The required reclamation was completed on , 20 and I inspected this site on , 20 and found all conditions to be in a satisfactory condition which should permit the issuing of a Reclamation Certificate. I understand that if the department finds the reclamation satisfactory, and if the operator is not indebt- ed to the department, the security deposit will be refunded.</p><p>Signature of Applicant Date</p><p>Information you provide to Alberta Environment and Parks (AEP) is collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act and is managed in accordance with Part 2 of the FOIP Act. The personal information you provide will be used by AEP for the purpose of administering the Public Lands Act and its associated regulations. Your personal information will not be used for any other purpose by AEP without your consent; however, it may be publicly disclosed to anyone requesting access of the record in accordance with Sections 166-167 of the Public Lands Administration Regulation.</p><p>Dec 4, 2015 Surface Materials Reclamation Certificate Request © 2015 Government of Alberta Page 1 of 2 Surface Materials Reclamation Certificate Request SML, SMC, DRS and Associated Access (DLO)</p><p>Operations Division</p><p>Information you provide to Alberta Environment and Parks (AEP) is collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act and is managed in accordance with Part 2 of the FOIP Act. The personal information you provide will be used by AEP for the purpose of administering the Public Lands Act and its associated regulations. Your personal information will not be used for any other purpose by AEP without your consent; however, it may be publicly disclosed to anyone requesting access of the record in accordance with Sections 166-167 of the Public Lands Administration Regulation.</p><p>Dec 4, 2015 Surface Materials Reclamation Certificate Request © 2015 Government of Alberta Page 2 of 2</p>