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05/5/1999 19:05 1-719-383-2211 ALLRITE PAV REDI MIX <br />• STATE OF COLORADO • <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_/ I request to be withdrawn from party status 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-_L- ~~ <br />PAGE 02 <br />t Z Qc claw~tum- Pcaw~- I.4-pQ(.GrQ t~,rv.. <br />For people who do not wish to become parties in this matter, information on the permit <br />applleation process can be requested i'tom the Division of Minerals and Geology. <br />~?~/~i~Y~rr c,~s~c~.~ <br />Printed Name <br />3 I ! ~.>t°u i t iii- <br />Aa~ress ~,., „ ~ /,v XID.Sa <br />City, State ' Zip Code <br />E-Mail Address <br />Signature <br />~ dip, 3s~Y- ~~~ ~ <br />Home Phone # <br />-S C.~~c~ <br />Work Phone # _ <br />FAX # <br />Date <br />IP you are requesting to be named as s 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 statemcnt 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 />