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, ' <br />STATE OF COLORADO <br />MINED LAND RECLAMATION BOARD <br />PAR3'Y STATiJS WITfIDRAW FORM <br />In the matter of File No. NI- -__ <br />Name of Operator/Applicant and Site: <br />Petmit/Permit Amendment Application. <br />_ I request I be withdrawn from party status 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,_ I request I be withdrawn from party status and I wish to address the Bord at the formal hearing, if 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 Bord 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not obligated to consider any issues raised by a party that has withdrawn.)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 Co become a party or withdraw as a parry in this <br />matter, please contact the Division for information on application status. <br />(Please provide the following information if you have or wish to have party status, thank yau.) <br />Printed Name <br />Address <br />City, State <br />U <br />Horne P66ne # <br />(_) <br />Work Phone # <br />Zip Code FAX # <br />E-Mai! Address <br />Date <br />Signature <br />