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r <br />~ >~. Y <br />STATE OF COLORADO . ~ ~, <br />MI D 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 \~~GO <br />a~~'~ ~1~~~~G ~~ <br />/ I request to be withdrawn from party status ~ ao <br />y h <br />In the matter of File No. M-f}~- r7_~: ~Q. `~`~~a <br />., <br />For people who do not wish to become parties in this matter, information on the permit <br />application process can be requested from the Division of Minerals and Geology. <br />STEr'r/~ It ~~ s <br />Printed Name <br />~. a. f~a~C /33~ <br />Address <br />,L ~,,.., CAD F~v S o <br />Ci ,State Zip Code <br />E- '1 Address <br />~ 7~~ <br />~- <br />Signa re ~B,~cCi6-w.,,.-~J.~'o~~ <br />3 <br />3o~~g~-855 <br />Home Phone # <br />f 3x31 Sao - ~ ~r/~ _ <br />Work Phone # <br />r3v3 , ~hd - sI9~3o <br />FAX # <br />s'- Zo <br />Date <br />IC you are requesting to be r-amed as a 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 statement to t1t1s 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 />i <br />~~ <br />