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STATE OF COLORADO <br />MID LAND RECLAMATION 1~RD <br />`I~=C;EI'JcC~ <br />PARTY STATUS REQUEST FORM <br />AP < .; 3 ZCCO <br />In the matter of File No. M- 2009-02 , Permit/Permit Amendment ApplicffAiot~ cl;;;i-„_,Zy t ~eC,c~,. <br />Name of OperatorlApplicant and Site: Mobile Premix Concrete / Tanabe Pit <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I request to be withdrawn from party status 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 />I understand that if I am not a party, my statements of concern or objection to this <br />application will not be considered during the review of the application, but I may address <br />the Board on this matter at the final hearing, and may present my concerns as an <br />interested member of the public. <br />For people who do not wish to become parties in this matter, information on permit <br />application status can be requested from the Division of Minerals and Geology. <br />Printed Name J 1f-~' <br />Ad ress ~,7 <br />City, State Zip C/ode <br />~v ~f {•,-.~ w ~ rho Ht h .(, l ~ ~`- <br />E-Mail Address <br />ature ~/ ~/ <br />If you are requesting to be named as a party, please briefly describe below: <br />1. how you maybe affected or aggrieved by the Board's decision in the matter referenced above, <br />2. your opposition to the matter, including a specific description of the issues that you feel need <br />to be addressed at the final hearing. (You may attach a written statement to this form instead <br />of using the space below.) <br />Rocky Mountain Mutual Housing Association, Inc., hereby adopts the <br />response of Pinnacle Pines LLC, dated April 3, 2000. <br />Home Phone # ~T y1 ~~ <br />~~JPhon~ FU~ <br />FAX # <br />Date <br />Jo /DO <br />