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FROM ..i a axa u~'v a ~. ~, uv...i ... ~. Mar. 19 200 III I II I II I II IIII III <br />MID LAND RECLAMATION B•RD <br />sss <br />PARTY STATUS REQUEST FORM <br />In the matter of File No. M-~- '(~ Permit/Permit Amendment Application. <br />Tame of Operator/Applicant and Site: C.4~titA~ ~--rxa2Gx ~~,~~ <br />' i~v~a/ VIFj~_(e-ia~~t~~c~- Wra .~ lex~NTY <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~ I request to be withdrawn from party status 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 />applicatiot 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 tan be requested from the Division of Minerals and Geology. <br />1~-tc <br />Printed Name <br />l ~4v9 wcR CG <br />Address <br />GfI2G_FJ,EY Gfl ~~iOG~ I <br />City, State Zip Code <br />~~~0~3~_ o~c.~4 <br />Home Phone #! <br />Work Phone # <br />FAX # <br />E-Mail Address <br />Signature ~ Date <br />If you are requesting to be named as a party, please briefly describe below. <br />1 how you may be 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 tksis form instead <br />of using the space below. ) <br />