REQUEST TO AMEND OPERATOR INFORMATION (ON SURFACE RIGHTS BOARD ORDER (including PUBLIC UTILITY BOARD ORDERS))

As per Section 29 (b) of the Surface Rights Act

Important Information on Requirements of this Application: To properly use this streamlined process, the new operator must be identified on the licence/permit/approval and the licence /permit/approval must be the one for which the original Order granting entry was made. If the request does not meet this requirement please refer to the instructions located on the website regarding section 29 of the Surface Rights Act.Part 1 APPLICATION INFORMATIONApplicant: Contact Name:

Address: Phone:

City: Province: Postal: E-Mail:

Indicate preferred method of receiving correspondence Mail E-Mail Fax

Part 2 OPERATOR TO BE NAMED ON BOARD ORDER (if different from Applicant)Applicant: Contact Name:

Address: Phone:

City: Province: Postal: Date licence/permit/approval takes effect

Part 3 BOARD ORDER TO BE AMENDED (Complete one application package for each Board Order to be amended)SRB File No. SRB Board Order No. Legal Land Description:

Part 4 REQUIRED DOCUMENTATION (check applicable field)YES NO 1) If the licence/permit/approval No. is identified on the Board Order - Provide a copy of the licence/permit/approval

reflecting the name of new operator (Note: the licence/permit/approval No. must be identical to the No. identified on the Board Order) (highlight the applicable No. if multiple numbers are listed). OR

2) If licence/permit/approval is not identified on the Board Order - Provide the completed "Statutory Declaration to Amend Operator Information" along with a copy of the licence/permit/approval attached sworn and commissioned.

NOTE: Board administration will not take action on this request unless all the materials/information required has been provided. If there are deficiencies,the request will be returned together with all submitted materialsPart 5 IN SUBMITTING THIS APPLICATION THE APPLICANT CONFIRMS (check applicable field): YES NO That the current landowners and / or recipients entitled to annual compensation were notified of this Application and

the Applicant is not in receipt of any objection(s) to the request.If you are requesting the Board to consider your application on a priority basis, please provide detailed reasons in support of same below.

Forward the completed application and all required supporting documents to the Board.

Surface Rights Board 1229 - 91 Street SW Edmonton, AB T6X 1E9

Telephone: 780-427-2444 www.surfacerights.alberta.ca

The information collected on this form is necessary to allow the Surface Rights Board to perform its function. The information is collected under the authority of the Freedom of Information and Protection of Privacy Act, section 33(c). Section 33(c) provides that personal information may only be collected if that information relates directly to and is necessary for the processing of your application. The information you provide will be considered a public record. If you have concerns with your information being part of the public record or if you have questions about how the Board deals with your information, please contact the Surface Rights Board Board Director.

SRB-OA-112618