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STATE OF COLORADO <br />MINED LAND RECLAMATION BOARD <br />PARTY STATUS WITHDRAWAL FORM <br />In the matter of File No. M- <br />Permit/Permit Amendment Application. <br />Name of Operator/Applicant and <br />I hereby withdraw as a party to this matter. <br />I hereby withdraw as a party to this matter and, if the Boazd holds a hearing, I wish to address <br />the Board at the formal hearing, ifheld, as anon-party. <br />(Please note that if all objecting parties withdraw prior to the date set for the Board's consideration of <br />the application, the application may be approved by the Office without the Board holding a hearing. <br />In that event, there will be no opportunity to address the Board on any issues related to the <br />application. Also, the Board is not obligated to consider any issues raised by a person or an entity that <br />has withdrawn as a party.) <br />Regardless of a party status, the Division thoughtfully considers each issue submitted in writing to the <br />Division and provides a response to those issues within its jurisdiction in the Division's "Rationale for <br />Recommendation." The Rationale is available to any person by contacting the Division. For persons who do <br />not wish to become a party or withdraw as a party in this matter, please contact the Division for information <br />on application status. <br />Printed Name Home Phone # <br />Address Work Phone # <br />City, State Zip Code FAX # <br />E-Mail Address <br />Date <br />Signature <br />