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16#1V1115 <br />STATE OF COLORADO MAY 2 5 2018 <br />MINED LAND RECLAMATION BOARD DIVISION OF RECLAMATION <br />MINING AND SAFETY <br />PARTY STATUS WITHDRAWAL FORM <br />In the matter of File No. M- ZOCT - O l7 , Permit/Permit Amendment Application. <br />Name of Operator/Applicant and Site: <br />Derr P <br />I hereby withdraw as a party to this matter. <br />MR <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a person or an entity that has withdrawn as a party.)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. <br />U5 U,_ La., LLc— <br />Printed Name <br />Pa J_ k,9 <br />Address <br />Kerse_tt co 80 (.,4-% <br />City, State ! �.Zip Code <br />OS <br />�dr,�ZZ crR r <br />Signature <br />12 <br />Home Phone # <br />} <br />Work Phone # <br />(970) 39't—�I1�1 <br />FAX 05/2 -2 -/tom <br />Date <br />