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STATE OF COLORADO • <br />MI 'sD LAND RECLAMATION BOARD <br />PARTY STATUS REQUEST FORM <br />~n <br />_ I request that I be named as a party <br />Q~.: ,~9q~ .od' <br />I request that I not be named as a party •~1 ~e° <br />I request to be withdrawn from party status o~~~~ <br />~o~ <br />0`'~ <br />In the matter of File No. M-~~7 - ~T7 <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 />~c,.vni'~ z;. ~o-n s <br />Printed Name <br />~v_ ~~ ~.~~~{ <br />Ad ess /. <br />~Yd 1~F 5 r L' U ~.~ S~ p <br />City, State Zip Code <br />E-Mail Address ~ <br />Signature <br />3a3~ 8?-3- S'K <br />Home Phone # <br />t3~3~ ~3d - g;1~0 <br />Work Phone # <br />t3c3 ~ g o_ ~f93o _ - <br />FAX # <br />,~~7irs /~ S <br />-•---~ <br />Date <br />If you are requesting to be named 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 lh~s form instead <br />of filling in the space below. ]nclude 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 />