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entity that has withdrawn as a party.)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