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<br />STATE OF COLORADO <br />MINED LAND RECLAMATION BOARD <br />PARTY STATUS WIT~IDRAW FORM <br />In the matter of File No. M-~-°`'~- ~ 6 Z , Petmit/Permit Amendment Application. <br />Name of Operator/Applicant and Site: C'%ean Ca-eeK ~~s~rr~t w~-l-~-r f~rovecf'~s ~,~-~ <br />M M 2 (? Qc~zznrv~y,. <br />X I request I be withdrawn from party status <br />_ I request I be withdrawn from party status and I wish to address the Bord at the formal hearing, if <br />held, as anon-party <br />(Please note that if all objecting parties withdraw rior to the date set for the Board's consideration of_the <br />application, the application may be approved by the Office and no Boazd hearing held. Thus, there will not be <br />an opportunity for any person to address the Board on any issues related to the application. Also, the Board is <br />not obligated to consider any issues raised by a party that has withdrawn.) <br />Regazdless of a party status, the Division thoughtfully considers each issue submitted in writing to the Division and <br />provides a response to those issues in the Division's "Rationale for Recommendation ". The "Rationale" is available to <br />any person by contacting the Division. For persons who do not wish to become a party or withdraw as a party in this <br />tnatter, please contact the Division for information on application status. <br />(PI A1(~ <br />~.v~tse ~, (JCvl~r (~3 ~ 27Fs-D379 <br />Printed Name Home Ptione # <br />39~~ ~tjcvu~~(as Mt-~, ~r , ~~ ~A h~e5 <br />Address n Work Phone # <br />Go1cfPn Co ~0'~3 ~ t'/~~ve~ <br />City, State , Zip Code FAX # <br />]iMail Address Date <br />Signature _ <br />