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STATE OF COLORADO MINED LAND <br /> RECLAMATION BOARD <br /> PARTY STATUS WITHDRAWAL <br /> FORM <br /> In the matter of File No. M- - Permit or Amendment Application. <br /> Name of Operator/Applicant: <br /> Site Name: <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, <br /> I 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 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 entity that has withdrawn as a party.)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 /> 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 /> Printed Name Home Phone # <br /> Address Work Phone # <br /> City, State Zip FAX# <br /> Code <br /> E-Mail Address Date <br /> Signature <br />