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:~ <br />STATE OF COLORAD~ <br /> <br />MINED LAND RECLAMATION BOARD <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I request to be withdrawn from party status <br />In the matter of File No. M- <br />For people who do not wish to become parties in this matter, information on the permit <br />application process can be requested from the Division of Minerals and Geology. <br />..io~.~~~~ll~ on <br />Printed Name <br />/.2 L°rr`P~~ <br />Address //~~ <br />~~ .JGrrd'Q l~r ~d <br />City, State Zip Code <br />~~~ o ~-~ ~ <br />Home Phone # <br />Work Phone # <br />FAX # <br />E-Mail Address <br />nl <br />tgnature <br />f ~ <br />ate <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 />