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i.~.J ia..: i~ni e,.~ '~7 b7. 35 <br />STATE OF COLORADO <br />I~ED LAND RECLAMATION B~RD <br />PARTY STATUS REQUEST FORM <br />I request that I be named as a party <br />_ I request that I not be named as a party <br />I request to be withdrawn from parry status <br />In the matter of File No. M- <br />Regardless of your status, please fill in your name and address so the Division can send you <br />information on this matter. <br />Printed Name <br />Address <br />City, State Zip Code <br />Home Phone # <br />t ~ <br />Work Phone # <br />1 1 <br />FAX # <br />Signature <br />Date <br />If you are requesting to be named as a party, please briefly describe below how you may be <br />affected or aggrieved by agency action in the matter referenced above, Include a statement of <br />your opposition or support in the matter. You may attach a written statement to this form instead <br />of filling in the space below. Include a specific description of the issues that you feel need to be <br />addressed at the final hearing before the Mined Land Reclamation Board. <br />