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STATE OF COLORADO <br />MINED LAND RECLAMATION BOARD <br />PARTY STATUS WITHDRAWAL FORM <br />In the matter of File No. M- - , Permit/Permit Amendment Application. <br />Name of Operator/Applicant and Site: <br />I hereby withdraw as a party to this matter. <br />I hereby withdraw as a party to this matter and, if the Board holds a hearing, I <br />wish to address the Board at the formal hearing, if held, as a non-party. <br />(Please note that if all objecting parties withdraw prior to the date set for the Board's <br />consideration of the application, the application may be approved by the Office without the <br />Board holding a hearing. In that event, there will be no opportunity to address the Board on any <br />issues related to the application. Also, the Board is not obligated to consider any issues raised by <br />a person or an entity that has withdrawn as a party.) <br />Regardless of a party status, the Division thoughtfully considers each issue submitted in writing <br />to the Division and provides a response to those issues within its jurisdiction in the Division's <br />"Rationale for Recommendation." The Rationale is available to any person by contacting the <br />Division. For persons who do not wish to become a party or withdraw as a party in this matter, <br />please contact the Division for information on application status. A. , <br />Printed Name <br />Home Phone # <br />Address Work Phone # , <br />City, State,., Zip Code FAX # <br />E -Mail Address <br />Signature <br />12 <br />Datt ' - j ' <br />