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STATE OF COLORADO <br />MINED LAND RECLAMATION BOARD <br />PARTY STATUS REQUEST FORM <br />~~G!aEi~i~D <br />I request that I be named as a party MAC 21 1999 <br />I request that I not be named as a party ~rviswn of Minerals 8 GeotoyY <br />I request to 1>e withdrawn from party status <br />In the matter of File No. M~~ ~ I - 0 S~ ; <br />For people who do not we~h to become parties in this matter, information on the permit <br />application process can be requested from the Division of Minerals and Geology. <br />~t L, ~ !d r S <br />Printed Name <br />P.G. r3K Sz f <br />Address <br />~~ c~ gos~d <br />City, State Zip Code <br />f~d3~SZ3 - qs'~q <br />Home Phone # <br />( 1 - <br />Work Phone # <br />r ~ - <br />F.AX # <br />E-Mail Address <br />,~ <br />Signature Date <br />If you are requesting to bc: 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 this 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 Boazd. <br />