Co Permittee Liability Release Form For Permits Page 2
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33150-FM-BWEW0271
10/2015
I hereby acknowledge that the co-permittee, as identified in Section 4 of this Liability Release Form, has
completed their responsibilities, as they pertain to the permit referenced above, and is withdrawing as a co-
permittee. Upon receiving written approval of this form from either the Department or conservation district, I
understand that the remaining permittee(s) and co-permittee(s), as applicable, shall be jointly and severally
responsible for compliance with all conditions of this permit and associated laws.
Name and Official Title of Permittee
Signature:
Date Signed:
, 20
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