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STATE OF COLORAD~ <br />MINED LAND RECLAMATION BOARD <br />PARTY STATUS FORM <br />In the matter of File No. M- , Permit/Permit Amendment Application. <br />Name of Operator/Applicant and Site: <br />I request that I be named as a party <br />I request that I not be named as a party <br />_ I request I be withdrawn from party status <br />_ I wish to address the Board at the formal <br />hearing, if held, as a non-party <br />_ I understand that I have party status <br />(Please note that if all objecting parties withdraw rip or to the date set for the Division's recommendation for <br />approval or denial, there may not be an opportunity for any person to address the Board on any issues related <br />to the application. If all objecting parties withdraw their objection after the above referenced date, the Board <br />may still hold a formal hearing, however the Board is not obligated to consider any issues raised by a party that <br />has withdrawn.) <br />Regardless 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 />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 you.) <br />Printed Name <br />Address <br />City, State <br />E-Mail Address <br />Signature <br />C) <br />Home Phone # <br />Work Phone # <br />(~-)- <br />Zip Code FAX # <br />Date <br />If you are not now a party and you wish to be named as a patty, please provide the following: <br />• How you may be affected or aggrieved by the Board's decision if the Board decides to approve the application. <br />(Please attach additional pages if needed) <br />Please explain your opposition to the matter, including a specific description of the issues that you fee{ need to be <br />addressed at the Formal Boazd Hearing and why. <br />(Please attach additional pages if needed) <br />